Billing and Medicaid (Apple Health)
Questions and answers about billing for services Medicaid covers. Read this if your medical provider didn't bill Medicaid for services when you think it should have. Includes sample letters you can use to try to resolve the situation. #5112EN
FAQ (Frequently Asked Questions)
Can a provider bill me for services I got while I had Medicaid (Apple Health)?
Usually, no. Medical providers taking part in Washington’s Medicaid program (Apple Health) must accept payment from the agency as payment in full. 42 C.F.R. § 447.15; WAC 182-502-0160; WAC 182-502-0010(2) (g). A provider generally cannot bill you for any service Medicaid covers even if the provider has not gotten payment from Apple Health or your managed care provider. WAC 182-502-0160(4) (b). We discuss exceptions to this below in section 2.
*The provider also cannot bill someone related to you, such as your family, a friend, or helper.
What if Medicaid does not cover all the cost of the service I got?
A provider cannot bill you for the cost of covered services over and above what Medicaid pays. They also cannot bill third parties, such as your spouse or other family, a friend, or a helper. Keep reading for exceptions to this.
What if I do not sign documents the provider gives me?
If you refuse to fill out and sign insurance forms, billing documents, or other forms the provider needs to bill a third-party insurance carrier for services you got, the provider may bill you for the service.
What if I got services from a provider who does not take Medicaid?
That provider may bill you only if you chose to receive their services even after it informed you of both of these:
- They do not contract with Medicaid.
- Medicaid would not pay for the services.
I am in a Managed Care Organization (MCO). What if I got services from a nonparticipating provider?
The provider can bill you if both of these are true:
- You knew the provider was outside your MCO’s network.
- You chose to get nonemergency services from it anyway without the MCO’s authorization.
They told me Medicaid would not cover the service. I chose to get the service anyway. Can they bill me?
Yes, if you agreed to pay the provider after it did all these:
- Checked if you could get Medicaid coverage for the dates of service.
- Checked if you had coverage under an MCO.
- Told you the limits of your coverage and services available to you.
- Signed a written agreement with you. (The provider generally should use this agency form. You can also see it at https://www.hca.wa.gov/assets/billers-and-providers/13_879.pdf.)
- Provided translation into another language if needed.
- Did everything Medicaid or your MCO required of it to authorize services, if coverage or authorization was available.
*A provider who did not complete the right paperwork at the right times cannot bill you if Medicaid or your MCO will not pay the provider.
Can the provider bill someone else for the service?
A medical provider can bill a “third party” who is legally responsible for paying any of the cost of your health care. This can be
- A person or entity that has caused you mental and/or physical harm.
- The insurance company covering that person or entity.
Example: You are in a car accident. The other driver is at fault. Medicaid pays for the medical services for your injuries. It will then try to recover the cost of your medical services from the other driver or the driver’s insurance company.
*You must “assign” (give) the State any right you have to payment from a liable third party for medical expenses, assistance, or residential care.
What if my Medicaid plan includes cost sharing?
Your medical provider can bill you for some costs. The provider can also bill you directly for
- Costs such as deductibles, coinsurance, or copayments.
- Services within your spend down amount, if you get Medically Needy Medicaid. Read The Medicaid Medically Needy Program: Medicaid for Adults 65 and Older or Disabled Who Don't Get SSI to learn more.
What about services I received in Canada?
Medicaid will pay for those services only if you got them in British Columbia and your situation meets other requirements. For example, one of these must be true:
- You live in Point Roberts, or in a community along the Washington/British Columbia border.
- You are a member of the Canadian First Nations and live in Washington State.
What about services I received out-of-state?
It depends. Medicaid will pay for services in these bordering cities on the same basis as in-state care:
- Coeur d’Alene, Moscow, Sandpoint, Priest River, and Lewiston, Idaho.
- Portland, The Dalles, Hermiston, Hood River, Rainier, Milton-Freewater, and Astoria, Oregon. WAC 182-501-0175
Medicaid will also pay for emergency and non-emergency out-of-state care that meets the requirements of WAC 182-501-0180.
How can I find out if I was covered by Medicaid for the dates of service?
Contact the Medical Assistance Customer Service Center (MACSC):
Online: Secure web form (https://fortress.wa.gov/hca/p1contactus/, then click client)
Business hours: weekdays 7 a.m. to 5 p.m. Pacific Time (PT) (except state holidays)
What if I did not have Medicaid for the dates I got the services?
The provider can bill you. Compare the dates you got the services to notices you got from Apple Health, your online account, or call the number on the back of your ProviderOne card. If the provider is billing you for any dates you had Medicaid, see Section 3 for sample letters you can use.
*If you tell the provider you are a private pay client and not getting medical assistance, the provider will bill you directly, even if you do in fact get Medicaid.
What if none of the exceptions applies to me?
The provider cannot bill you. Section 3 has sample letters you could use. Or contact a lawyer.
What if an exception applies?
If the provider should have had a written agreement with you, ask them to give you a copy. See “They told me Medicaid would not cover the service. I chose to receive the service anyway,” above. Compare the agreement you signed to what WAC 182-502-0160(5) requires. If the agreement does not say what it should, sample letter 3 below might convince the provider not to bill you.
*All sample letters are attached below.
Keep a copy of the letters you send. Make a note on your copy of how you delivered the letter and the date you delivered it. For example, “sent on 8/22/2021 by regular US mail” or “hand-delivered to [provider name] billing dept. on 8/22/2021”.
Sample letter 1: Use this if you start to get bills from a provider even though you told them at the time of service that you had Medicaid.
Sample letter 2: Use this if you sent sample letter 1 and the provider keeps billing you anyway.
Sample letter 3: Use this if Medicaid covered some, but not all, of your bills. The provider claims you signed a waiver.
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