Billing and Medicaid (Apple Health)
Authored By: Northwest Justice Project
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
- Can a provider bill me for services I got while I had Medicaid (Apple Health)?
- What if Medicaid does not cover all the cost?
- What if I do not sign documents the provider gives me?
- What if I received services from a provider who does not take Medicaid?
- I am in a Managed Care Organization (MCO). What if I got services from a nonparticipating provider?
- Can the provider bill someone else for the service?
- What if my Medicaid plan includes cost sharing?
- What about services I received in Canada?
- What about services I received out-of-state?
- How can I find out if I was covered by Medicaid for the dates of service?
- What if I did not have Medicaid for the dates I received the services?
- What if none of the exceptions applies to me?
- What if an exception applies?
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 the exceptions to this below in section 2.
- “You” here also means the provider cannot bill someone related to you, such as your family, a friend, or helper.
A provider cannot bill you for the cost of covered services over and above what Medicaid pays. This also applies to third parties, such as your spouse or other family, a friend or a helper. Keep reading for exceptions to this.
If you refuse to complete and sign insurance forms, billing documents, or other forms the provider needs to bill a third-party insurance carrier for services you received, the provider may bill you for the service.
That provider may bill you if you chose to receive their services after it informed you of both of these:
They do not contract with Medicaid.
Medicaid would not pay for the services.
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 receive 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.)
Provided translation into another language if needed.
Did everything Medicaid/your MCO required of it to authorize services, if coverage/authorization was available.
*A provider who did not complete the right paperwork at the right times cannot bill you if Medicaid/your MCO will not pay the provider.
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/entity that has caused you mental/physical harm.
The insurance company covering that person/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 seek 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.
Under the terms of your coverage, 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. The Medicaid Medically Needy Program: Medicaid for Adults 65 and Older or Disabled Who Don't Get SSI has more info.
Medicaid will pay for those services only if you received 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.
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.
Medicaid will also pay for emergency and non-emergency out-of-state care that meets the requirements of WAC 182-501-0180.
Contact the Medical Assistance Customer Service Center (MACSC):
The provider can bill you. Compare the dates you received 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 receiving medical assistance, the provider will bill you directly, even if you do in fact get Medicaid.
The provider cannot bill you. Section 3 has sample letters you could use. Or contact a lawyer.
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 in this publication might convince the provider not to bill you.
Keep a copy of the letters you send. Make a note on your copy of the date and how you delivered the letter. For example, “sent on 8/22/2018 by regular US mail” or “hand-delivered to [provider name] billing dept. on 8/22/2018”.
Sample letter 1: 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: You sent sample letter 1. The provider keeps billing you anyway.
Sample letter 3: Medicaid covered some, but not all, of your bills. The provider claims you signed a waiver.
This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal advice.
This information is current as of September 2017.
© 2017 Northwest Justice Project — 1-888-201-1014
(Permission for copying and distribution granted to the Alliance for Equal Justice and to individuals for non-commercial purposes only.)