Top 25 Medicaid FAQs Providers Ask

Answer: Medicaid typically pays 60-80% of Medicare rates, but this varies widely by state and service:

• Primary care: 50-100% of Medicare (varies by state)
• Specialists: 40-80% of Medicare
• Behavioral health: Often matches or exceeds Medicare in some states
• Procedures: 60-90% of Medicare

Some states have enhanced reimbursement for specific services (e.g., maternity care, pediatrics).

Answer: Timely filing limits vary by state:

• 90 days: Texas, Florida
• 120 days: Ohio, Indiana
• 180 days: California, Pennsylvania
• 365 days: New York, Illinois

Best practice: Submit all Medicaid claims within 60 days to allow time for corrections.

Answer: Clean claims are typically paid within:

• FFS Medicaid: 14-30 days
• MCO plans: 30-45 days

Many states have prompt-pay laws requiring payment within 30 days of clean claim submission. Late payments may accrue interest.

Answer: No. Federal law prohibits balance billing Medicaid beneficiaries for covered services. You must accept Medicaid payment as payment in full.

You can only bill patients for:

• Services not covered by Medicaid (with prior notification)
• Copayments (if applicable to the patient's plan)
• Services provided when patient was not eligible for Medicaid

Answer: It depends on the state and the patient's category:

• No copays: Pregnant women, children under 18, emergency services
• Nominal copays ($1-$4): Some states for office visits and prescriptions
• Higher copays: Non-emergency ER use (up to $8)

Important: You cannot deny service for failure to pay copay. Copays are optional collections.

Answer: Almost all states! 40+ states use managed care for the majority of Medicaid beneficiaries. Only a few states (Alaska, Connecticut, Wyoming) rely primarily on fee-for-service.

In managed care states, 70-90% of beneficiaries are enrolled in MCO plans.

Answer: Aim for 3-4 of the largest MCOs in your state to capture 70-80% of the Medicaid market.

Research which MCOs have the highest enrollment in your region. UnitedHealthcare Community Plan, Molina, Centene (multiple brands), and Aetna Better Health are common national players.

Answer: Sometimes, but it's difficult. MCO contracts are often "take it or leave it" for individual providers.

Negotiation leverage exists if you:

• Are in a high-demand specialty
• Practice in an underserved area
• Have a large patient panel or multi-location practice
• Offer specialized services (e.g., SUD treatment, ABA therapy)

Fee-for-Service (FFS):

• Bill state Medicaid agency directly
• Standardized rates set by state
• Simpler authorization processes

Managed Care (MCO):

• Bill individual MCO plan
• Rates vary by MCO
• More authorization requirements
• Often better customer service and faster payments

Answer: It depends on the service and the plan (FFS vs MCO):

• FFS: Limited prior auth (mainly for high-cost services, DME, some procedures)
• MCO: More extensive prior auth requirements (imaging, therapy, specialty referrals)

Always verify authorization requirements before providing service.

Answer: Yes. Medicaid is the largest payor of behavioral health services in the U.S., covering:

• Outpatient therapy (individual, group, family)
• Medication management
• Intensive outpatient programs (IOP)
• Partial hospitalization programs (PHP)
• Residential treatment
• Substance use disorder (SUD) treatment
• Peer support services
• Case management

Answer: Yes, in most states. Medicaid covers licensed clinical social workers (LCSW), licensed professional counselors (LPC), and licensed marriage and family therapists (LMFT).

Some states require these providers to work under a physician or psychologist's supervision for reimbursement. Check your state's Medicaid provider manual.

Answer: Most states do not have hard visit limits for outpatient therapy, especially for children. Medical necessity determines coverage.

However, MCO plans may have soft limits and require authorization after a certain number of visits (commonly 10-20 sessions).

Answer: Yes. All states expanded telehealth coverage during COVID-19, and most have made these changes permanent for behavioral health services.

Telehealth reimbursement typically matches in-person rates. Some states require specific modifiers or place of service codes.

Answer: SUD treatment reimbursement varies widely but has improved significantly due to the opioid crisis and federal funding:

• Outpatient counseling: $40-$80 per session
• IOP: $100-$200 per day
• Residential treatment: $150-$400 per day
• MAT (medication-assisted treatment): Often well-reimbursed

Answer: Yes, but there are notice requirements. Most states require 60-90 days advance written notice. You must continue seeing established Medicaid patients during the notice period.

Answer: Redetermination is the process where states verify a patient's continued Medicaid eligibility (typically annually). Many patients lose coverage due to administrative issues even if still eligible.

Provider tip: Always verify eligibility at each visit. Patients who lose Medicaid may qualify for marketplace coverage.

Answer: Yes. Most states are required to provide non-emergency medical transportation (NEMT) to Medicaid appointments for beneficiaries who have no other means of transportation.

Patients must request this in advance (typically 48-72 hours). It's not automatic.

Answer: Yes. Many providers accept both. Some patients are "dual eligible" (both Medicare and Medicaid), meaning Medicare pays first and Medicaid covers copays/deductibles.

For dual eligible patients, bill Medicare first, then submit to Medicaid for the remaining balance.

Answer: Each state publishes a Medicaid Provider Manual on their Medicaid agency website. This includes:

• Covered services
• Billing procedures
• Authorization requirements
• Reimbursement rates
• Timely filing limits
• Appeal processes

PayorHelp tip: Browse our state-specific Medicaid guides for easier navigation.