Medicaid

Medicaid is our nation's largest health care plan and covers one in five Americans. Enacted in 1965 under Social Security Act Title 19, Medicaid is a public health insurance program for low-income children, adults, seniors and people with disabilities. The Children's Health Insurance Program (CHIP) serves uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid. The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for Medicaid beneficiaries under the age of 21 years.

The rules governing Medicaid programs vary by location. Although subject to federal standards, individual states administer the Medicaid, CHIP and EPSDT programs with the authority and flexibility to determine who is eligible, design and coverage, health care delivery models, benefits and methods for paying providers and hospitals. Because of this flexibility at the state level, there is tremendous variation across state Medicaid programs.

TIP: The Academy works with state affiliate and DPG/MIG leaders who serve as "nutrition services payment specialists" to help fellow members understand Medicaid details specific to their state and/or practice specialty.

Eligibility

While most Medicaid eligibility is based on modified adjusted gross income and tied to the federal poverty level, adults may apply for Medicaid if they are terminally ill and want hospice services; eligible for Medicare and have low income and limited resources; are 65 years old or older, blind or disabled and have low income and few resources; live in a nursing home; or need nursing home care but could remain at home with special community care services.

The Children's Health Insurance Program (CHIP) serves uninsured children up to age 19 in families with incomes too high to qualify them for Medicaid. States have broad discretion in setting their income eligibility standards, and eligibility varies across states.

The Patient Protection and Affordable Care Act (ACA) gave states the option to voluntarily expand Medicaid coverage to include low-income adults previously excluded from the program and provided federal funding for a majority of the costs associated with the newly eligible adults.

Design and Coverage

The Patient Protection and Affordable Care Act also expanded opportunities for RDNs to provide MNT under the essential health benefit category of Preventive and Wellness Services. Under the legislation, preventive care services related to MNT provided by RDNs include "dietary counseling for adults at higher risk for chronic disease" and "obesity screening and counseling for all age groups." However, RDNs must refer to their individual state Medicaid plan for detailed coverage information.

Medicaid Benefits

Federal law requires states to provide certain "mandatory" Medicaid benefits while allowing them the choice of covering other "optional" benefits. Nutritional coverage details are not outlined specifically as Medicaid benefits; however, MNT could potentially fall under "Other diagnostic, screening, preventive and rehabilitative services." Healthy diet counseling and obesity counseling are two services covered by many state Medicare programs. For any Medicaid benefits, the individual state determines the type, amount, duration and scope of services within these broad federal guidelines.

Medicaid and Medicare Dual Eligible Coverage

Dual Eligible Beneficiaries are individuals enrolled in both Medicare and Medicaid, including those enrolled in Medicare Part A, Medicare Part B, or both who receive full Medicaid benefits, assistance with Medicare premiums, cost sharing benefits or any combination thereof. Services covered by both Medicare and Medicaid generally are paid first by Medicare.

The options for dual eligible individuals to receive their Medicare and Medicaid benefits vary by state. In some states, dual eligible individuals receive Medicaid through Medicaid Managed Care plans, and in other states, Medicaid coverage may be Fee-For-Service. And in some states, certain dual eligible individuals can join plans that include all Medicare and Medicaid benefits.

Medicaid Delivery Models

Individual state Medicaid plans are offered in a variety of delivery models, which could include a traditional fee-for-service plan or Managed Medicaid plan. Within a particular state (and even between different delivery models of Medicaid plans in the same state), Medicaid coverage for MNT can vary in how a benefit is defined and who can provide the service.

Traditional Fee-for-Service Medicaid Programs

Although the federal government does not require states to provide any benefits for MNT or nutrition counseling services through Medicaid, CHIP or EPSDT, about half of states have elected to add some benefits for nutrition. Of those states, some may recognize RDNs as independent billing providers under Medicaid. In other states, RDNs can provide the actual service, but only physicians or primary care providers are the recognized billing provider.

States that chose to expand their Medicaid programs under the Patient Protection and Affordable Care Act are required to include preventive health screening and counseling services. In some areas, RDNs may be able to provide the dietary and behavior change counseling services associated with these recommendations. However, RDNs must refer to their individual state Medicaid plan for detailed coverage information.

Medicaid Managed Care Programs

The majority of Medicaid beneficiaries nationwide receive Medicaid program health care services through Medicaid Managed Care Programs, which significantly reduce program costs and better manage utilization of health services by contracting with Managed Care Organizations (MCOs) to deliver services. These MCOs accept a set per member per month—known as "capitation"—payment for providing health care services to the state Medicaid beneficiaries.

Enrolling as a Medicaid Provider

RDNs seeking to enroll to provide MNT services to Medicaid or Children's Health Insurance Program (CHIP) beneficiaries will need to enroll as a Medicaid Provider in the particular state they would like to provide services, as these programs are administered by individual states. Eligibility requirements to become a provider vary by state and some states do not recognize RDNs as Medicaid providers.

Medicaid is a decentralized program that is managed at the state level. To locate instructions for how to enroll in a specific state's Medicaid Program or CHIP, RDNs can conduct a web search using the terms: "state" + "Medicaid provider enrollment" (NOTE: Replace "state" with the name of the state where you seek to enroll)

Telemedicine and Telehealth

While the federal Medicaid statute does not recognize telemedicine as a distinct service, individual states can elect to cover telemedicine. State Medicaid plans may or may not cover services provided under telehealth (which is not the same as telemedicine under Medicaid).

Medicaid defines telemedicine as using telecommunications technologies to support the delivery of all kinds of medical, diagnostic and treatment-related services, usually by doctors.

Medicaid defines telehealth as similar to telemedicine, but telehealth encompasses a wider variety of remote healthcare services beyond the doctor-patient relationship—including services provided by other members of the healthcare team who help with health education, social support, medication adherence and troubleshooting health issues for patients and their caregivers.

Medicaid guidelines require all providers to practice within the scope of their State Practice Act. Some states require providers using telemedicine technology across state lines to be licensed in the state where the patient is located. All telemedicine requirements or restrictions placed by the state are binding under current Medicaid rules.

Ultimately individual states decide whether to cover telemedicine and determine what types of telemedicine to cover; where in the state it can be covered; how it is covered; what types of telemedicine providers may be reimbursed (as long as such providers are "recognized" and qualified according to Medicaid regulation); and how much to reimburse for telemedicine services—as long as such payments do not exceed Federal Upper Limits.

Important: The information found on this and all eatrightPRO.org pages is for reference only and does not constitute the rendering of legal, financial, or other professional advice of the Academy of Nutrition and Dietetics.