At age 98, Jamison truly is his family’s patriarch. His children want him to attend the annual family reunion. The problem? Jamison lives in Alabama. The reunion is in Texas. Although he does not live in a nursing home, Jamison requires some skilled nursing care and is legally blind. They are concerned that Jamison’s Medicaid benefits will not pay for medical services while he is away from Alabama.
Jamison’s family is right to be worried. Although the funds for Medicaid benefits come from the federal government, individual states manage Medicaid for their citizens. Jamison’s Medicaid benefits, then, are administered by Alabama Medicaid. Individual states are allowed to develop their own rules and regulations, as long as they comply with federal regulations.
It’s the Law
Federal law at 42 CFR 431.52 provides that state plans will pay for services provided to Medicaid recipients who are temporarily out-of-state. However, the following conditions must be met:
(1) Medical services are needed because of a medical emergency;
(2) Medical services are needed, and the beneficiary’s health would be endangered if he were required to travel to his State of residence;
(3) The State determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other State;
(4) It is the general practice for beneficiaries in a particular locality to use medical resources in another State.
The law goes on. States are required to establish procedures so individuals who are eligible for Medicaid under another state’s program can receive medical services.
But It May Not Be Easy
Note that medical costs incurred during an emergency are covered. This means that individuals may be billed for services related to non-emergencies, unless that care fits the other criteria listed above. Also, the out-of-state provider has to enroll as a provider with the Alabama Medicaid Agency. And, finally, some services have to be pre-approved.
Medicaid Is a Complex Program.
Schedule a consultation with one of the attorneys at Adams & Miller, PC, and find out where you stand. Our phone number is 256-251-2137, or you may want to use the Contact Form on our website. We have offices in in Anniston and Birmingham and assist clients in communities like Hoover, Vestavia Hills, Irondale, and Calera.