Charges Beneficiary’s Responsibility

Charges Beneficiary’s Responsibility A. Medicaid beneficiaries may be charged for the following: 1. The beneficiary is responsible for all expenses for non-covered services, such as services that are not covered under the scope of the Medicaid program, or services received in excess of program benefit limitations. The beneficiary is responsible for services received during a period of ineligibility. 2. Any applicable cost-sharing amount applied by the Medicaid program is the responsibility of the beneficiary. 3. Beneficiaries enrolled in managed care programs that insist upon receiving services that are not authorized by the primary care provider (PCP) may be required to pay for such services. For example, if the beneficiary seeks care in a hospital emergency room (ER) for services that can be provided in the PCP’s office and are not authorized by the PCP for treatment in the ER; the beneficiary may be responsible for payment of the ER services beyond the medical assessment. The beneficiary sees a specialist for services that are not excluded from managed care and are not considered emergent/urgent, and the PCP has not made the referral or denies authorization; the beneficiary may be responsible for payment of such services. 4. The beneficiary, or responsible adult, is held accountable and responsible for knowingly allowing or continuing to allow an unauthorized person to use a Medicaid card or beneficiary’s identity to obtain benefits otherwise not allowed. Any charges to or payments by the Division of Medicaid for services requested and/or received in an attempt to defraud the provider of services and/or Medicaid are billable to the cardholder or his/her responsible party, or the imposter. B. This list is not all-inclusive.