How Medicaid Covers PA Services

What is Medicaid?

Medicaid, authorized by Title XIX of the Social Security Act and jointly funded by federal and state governments, is a program that provides medical assistance for low-income individuals, families, children, the aged and the disabled. Although the federal government sets basic guidelines and pays 50 percent to 80 percent of the cost of Medicaid (depending on the state’s per capita income), individual states administer the program, decide (for the most part) who can provide medical care, and reimburse providers for their service.

The Medicaid program began on January 1, 1966, and now covers more than 50 million people. Due to the expansion of Medicaid authorized by the ACA, the number of enrollees in Medicaid is expected to increase.

Within federal guidelines, states decide which groups their Medicaid programs will cover and the financial criteria for eligibility. The categorically needy must be covered; this includes recipients of supplemental security income (SSI) and families with dependent children receiving cash assistances. Other low-income mandatory groups include pregnant women and infants and certain low-income Medicare groups.

Medicaid coverage of PA services

Unlike the Medicare program, which mandates coverage of services provided by PAs, each state determines whether PAs are eligible providers under its program. All states and the District of Columbia cover PAs in the fee-for-service or managed care plans at the same or lower rate as that paid to physicians.

States vary in how they want PAs to identify themselves as a provider of service. In some states, medical services provided by PAs are billed under the physician’s name. In other states, PAs use a modifier code to identify their services. In the majority of states (43 and the District of Columbia) Medicaid programs enroll or credential PAs and require them to bill with their own identifier as rendering provider.

PAs should check with the Provider Enrollment or Provider Relations Department of their Medicaid office to determine the registration process (if any) and the billing procedures.

For additional information about state Medicaid programs, contact the reimbursement department at 703-836-2272 or email the reimbursement team at [email protected].