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DHS Confirms Providers Cannot Collect Insurance Copays From Children Eligible for Medicaid

At the urging of Disability Rights Wisconsin, the Department of Health Services has issued a letter clarifying that providers cannot collect insurance copays from the families of Medicaid eligible children for services that are covered by both Medicaid and the family’s insurance.  The issue arises most often for families who have private health insurance which covers autism services and whose child is also enrolled in the Children’s Long Term Support (CLTS) Medicaid Waiver program.  Many insurance policies have hefty copays for intensive in-home services.  These services are also covered by the CLTS Waiver.  Insurance is the primary payer for these services.  Typically the actual insurance payment (without the copay) exceeds the Medicaid reimbursement rate for the same services.  Medicaid may sometimes make an additional payment for the service provided, if the amount private insurance pays is less than the Medicaid payment rate, but under no circumstances can the provider collect the copay from the family.  Federal and state law prohibit providers from charging a Medicaid recipient under age 18 any copay.

As DHS put it to providers: “…the family is not liable for any copayment for the service.  A co-payment would only be allowed if the child is not enrolled in a medical assistance program or the service provided is not an MA covered service….”

Follow this link to see the letter from DHS: DHS letter to providers CLTS co-payments 11-18-2013.

The issue arose because of misleading guidance issued by DHS in June of 2012 which was interpreted as allowing providers to collect insurance copays from Medicaid recipients even if the services they provided were also covered by Medicaid.  After learning of the problem DRW contacted DHS and requested that it issue the clarification letter.  DRW has, separately, also contacted most of the providers of intensive in-home autism services and made them aware of the federal rules and the potential consequences of violating them.

One important issue is not addressed by the DHS letter-the matter of refunds.  Any family who paid a provider based on one of these illegal copays should get a refund.  DRW will be sending a letter to providers reminding them of this obligation.  People who have paid such a copay should ask their provider for a refund.  If the provider does not issue it you should call DRW.