Medicaid Payment Expectations
Medicaid and Other Insurance
You may hear Medicaid referred to as the "payer of last resort."
This means that all other forms of insurance will be
exhausted before your Medicaid coverage pays for services and
drugs. It is important to understand that your medical bills will
first be paid by any private insurance coverage that you may have
through your employer or possibly the employer of your spouse or
parents, depending on your marital status and age. Following
private insurance, if you are a Medicare recipient, Medicare will
pay medical bills. Medicaid will then cover remaining authorized
expenses after all of your liabilities are met.
Co-Pays
Co-pays are an agreed upon rate that you pay out of pocket for a
service or drug at the time of purchase. An example of a co-pay is
when filling a prescription for a generic drug through your local
pharmacist: you will pay a $3.00 co-pay for the drug. Co-pays
vary per Medicaid program, and some may not have any co-pays for
drugs or services.
Premiums
Premiums are out of pocket expenses that you will pay to
maintain your insurance coverage through Medicaid. You may be
required to pay a premium if you are enrolled in Hoosier Healthwise
or the Healthy Indiana Plan. For example, if you are a member
of the Healthy Indiana Plan (HIP), you may have a premium of $45.00
that you must pay each month in order for your HIP coverage to
continue. If you do not pay the premium, you will not
continue to have the insurance. It is very important that if
you have a premium you pay it on time each month so you do not lose
coverage. If you lose coverage because of non-payment, you
will have to reapply for the program and could potentially be put
onto a waiting list or denied coverage for a determined amount of
time due to your lapse in payment. Premiums vary per Medicaid
program, and some programs may not have any premiums. You will be
notified of a premium when you are notified of your enrollment into
Medicaid.
Spend-down
In certain cases, a Medicaid member may have income or resources
that are too high to qualify for Medicaid services; in these cases,
the member has what is called a spend-down. A spend-down is the
amount of money a person must spend on qualified medical expenses
each month before Medicaid will pay for services. After the
spend-down is met each month, Medicaid will begin to cover the
remaining medical expenses that you have incurred. An example of
spend-down is:
Your income is $1000.00 monthly.
The income limit for Medicaid is $700.00 per month.
The spend-down is the difference between the income limit
($700.00) and your income ($1000.00) equaling $300.
Therefore, you must incur $300.00 in medical expenses each month
before Medicaid coverage will begin to pay for services. You can
meet your spend-down by paying for any medical service that is
covered by your Medicaid program. This includes prescription
drugs or doctor visits. REMEMBER: This is just an example and
is not indicative of what the income limits are or what your
spend-down will be if you are over the income limit. Many members
do not have a spend-down at all. You will be notified of any
spend-down you will have when you are notified of acceptance into
Medicaid.