Opinion ID: 2638118
Heading Depth: 3
Heading Rank: 2

Heading: Federal and State Medicaid Program

Text: The Medicaid program, codified at Title XIX of the Social Security Act, 42 U.S.C. §§ 1396-1396v, is a voluntary federal-state partnership through which the federal government gives participating states funds to assist them in providing health care to eligible needy individuals. [9] Participating states must comply with the statutory provisions of the Medicaid act as well as regulations promulgated by the Secretary of Health and Human Services. [10] Alaska participates in the Medicaid program. [11] The Department of Health and Social Services (DHSS) administers the program in Alaska. [12] DHSS contracts with health care providers for Medicaid services. [13] Under these provider agreements, providers agree to furnish medical care to eligible individuals in exchange for reimbursement from the state. [14] Even though the Medicaid rates for services are often lower than a provider's typical fees, providers must accept the state-approved Medicaid payment as payment in full for the services rendered. [15] The only exception is that providers may charge recipients authorized cost-sharing including copayment amounts. [16] The prohibition on charging a recipient for any amount exceeding the authorized cost-sharing charges is commonly referred to as the prohibition against balance billing. [17] A provider may not deny services to an eligible individual based on the individual's inability to pay the copayment. [18] But an individual's inability to pay does not eliminate his liability for copayment charges. [19] DHSS has contracted with First Health to process Medicaid claims. First Health reviews charges submitted by medical providers and determines how much Medicaid will pay for the services rendered. After First Health makes its determination, it gives the provider a remittance advice that lists the approved payment amount, any denials, and any copay amount that the provider may charge the Medicaid recipient. The state does not provide the Medicaid recipient with a copy of the remittance advice. The bills Smallwood received from the hospital did not list First Health-approved copay amounts.