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 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 and Contributions
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 M.E.D. Works. You may also be required to make a
contribution for the Healthy Indiana Plan. For example, if
you are a member of the Healthy Indiana Plan (HIP), you may have a
monthly contribution of $20.00 that you must pay each month in
order for your HIP coverage to continue.
If you do not pay the premium or contribution, you will not
continue to have the insurance. It is very important that if
you have a premium or contribution, 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 denied coverage for a determined amount of time due
to your lapse in payment. Premiums and contributions vary per
Medicaid program, and some programs may not have any premiums or
contributions. You will be notified that you will be responsible
for a premium or contribution once you have received your
determination notice from the Division of Family Resources.
The spend-down provision was removed for most Indiana Medicaid
recipients due to the recent eligibility changes for the aged,
blind, and disabled. For more information about these
changes, please refer to the Medicaid Disability
Eligibility Changes webpage.
Most individuals residing in long term care facilities,
including nursing homes, will be responsible to pay a portion of
their income to the long term facility, and Indiana Medicaid would
pay the remainder of the nursing home costs and other covered
medical expenses. This is known as the "patient
liability". Certain deductions are allowed from the person's
income when determining the amount that needs to be paid to the
facility. Such deductions include: a personal needs
allowance, premiums for other health insurance coverage, a spousal
allocation that provides income support to the spouse that lives at
home, medical expenses not covered by Indiana Medicaid or other
third party insurance, and court-ordered guardianship not greater
than $35 per month.
Some individuals that are receiving home and community
based services under an Indiana Medicaid waiver may have to pay a
portion of their monthly income for some medical expenses if their
income exceeds a certain amount. This is known as the "waiver
liability" and is the portion of the monthly medical expenses that
the individual would be responsible in paying to a certain
provider(s). Indiana Medicaid would pay the remainder of the
medical expenses for that month.