sets the reimbursement coverage and limitation policies
for DC's Medicaid program. Policies that govern Medicaid
allow for the payment of a variety of medical services.
HealthCheck Medicaid Provider Billing Manual:
- Fee-for-service – the
provider is paid a fee for each procedure performed
reimbursement ("per diem" or "encounter" rate) – based
on the provider’s
actual cost for rendering services to Medicaid member.
reimbursement -- A MCO is paid
a fixed amount
each month for each recipient (per capita) who is enrolled
and Billing Issues
to Payment Provisions. Medicaid will not reimburse for services for Medicaid members
if non-Medicaid members are provided the same service free of
charge. The only exceptions
are services provided by agencies that receive federal funds
- Title V Maternal
and Child Health of the Social Security Act (i.e., public health
B or C of the Individuals with Disabilities Education Act
early intervention or special education health-related services).
Inability to Pay. A provider cannot deny service to EPSDT members between ages 18
and 21 based solely on the recipient’s inability to pay
a Medicaid co-payment amount.
recipient is unable to pay at the time services are rendered:
- The provider
bill the recipient for the unpaid charge.
- Cost sharing
is allowed for prescription drugs ($1) and eye glasses
- There is
no cost sharing for HealthCheck recipients under
age 18 (DC Medicaid Program Transmittals No. 95-29 and 95-25).
Members for Administrative Services. Participating
Medicaid providers are prohibited from charging for the
completion of children’s
Note: A charge is defined as “cost