Medicaid Provider Enrollment for Out-of-State Children’s HealthcareMore than 2 million children living in the U.S. have rare or complex illnesses requiring specialized medical care that is available only at a limited number of pediatric healthcare organizations.
Medicaid Provider Enrollment for Out-of-State Children’s Healthcare
More than 2 million children living in the U.S. have rare or complex illnesses requiring specialized medical care that is available only at a limited number of pediatric healthcare organizations.
Children with medical complexity (CMC) have multiple significant chronic health problems that result in functional limitations and high healthcare need or utilization. These children, who typically rely on multiple pediatric medical and surgical specialists, must often travel to pediatric healthcare organizations in another state to receive their medical care.
Children with medical complexity are often enrolled in Medicaid. Children who are eligible for Medicaid on the basis of a disability are more likely to have out-of-state hospital stays than other types of Medicaid patients. In 2013, about 2 percent of Medicaid hospital stays occurred out of the patient’s state of residence. Disabled children have a higher share of out-of-state inpatient hospital stays (4.1 percent) than non-disabled children (2.2 percent), disabled adults (2.0 percent), and non-disabled adults (1.5 percent). Children’s hospitals serve a higher share of patients from out of state than other types of hospitals. In 2013, only 44.9 percent of hospitals provided care to Medicaid patients who lived outside the state where the hospital was located. Yet 86.4 percent of children’s hospitals served out-of-state patients, a higher share than other hospital types.
The use of out-of-state care may increase when Medicaid’s Advancing Care for Exceptional Kids Act (ACE Kids Act) is implemented on Oct. 1, 2022, by states that choose to participate. Aiming to improve care coordination for children with medical complexity, the ACE Kids Act includes provisions to ease access to necessary care across state lines.
Medicaid partially or fully covers care, including out-of-state, for CMC. Each state determines pay rates for services provided out of state. Many states pay out-of-state providers at lower rates than in-state providers. As of November 2018, 18 states and the District of Columbia paid out-of-state hospitals using the in-state rate for inpatient hospital services in their fee-for-service (FFS) Medicaid programs, and the remaining 32 states paid a different out-of-state rate.
To receive payment for Medicaid services, out of state providers must enroll with the Medicaid program in the patient’s state of residence and meet federal screening requirements. If a child living in Oklahoma travels to Texas for treatment, the provider at the Texas healthcare organization must be enrolled in Oklahoma’s Medicaid program to be reimbursed for providing care to that patient. Each state determines the process providers must follow to enroll as an out-of-state Medicaid provider, and state Medicaid agencies carry out the background screening and enrollment.
State requirements for screening and enrolling out-of-state Medicaid providers vary widely in their complexity and can cause a significant administrative burden to both the providers and the teams responsible for managing these enrollments. Some states, such as California, do not require separate screening for out-of-state providers and have established an express enrollment process for them. Other states that do require full enrollment must be properly researched to ensure a clean application with all required supporting documentation is submitted and processed as quickly as possible.
It is critical to understand the unique state requirements surrounding the enrollment process, which can range from the need for wet signatures on paper applications, to scheduling fingerprinting appointments for background screening, to mandating the attachment of existing claims from patients who have already received treatment. Once acceptance from Medicaid has occurred, it is also imperative to maintain that status through mandatory revalidation, which can beget a new set of requirements.
The intention is good: protecting patients by weeding out fraudulent or abusive providers. Unfortunately, however, the red tape involved in vetting and enrolling out-of-state providers (who are already enrolled in Medicaid in their home state) often delays the delivery of care, making that treatment more difficult and expensive when it is finally administered.
Boston Children’s Hospital reported several examples of barriers to Medicaid out-of-state provider enrollment. A nationally recognized specialty surgeon was asked to provide a copy of his original Social Security card—not something most people can quickly locate—to enroll in another state’s Medicaid program. This request was made despite The Centers for Medicare and Medicaid Services’ instructions to states to stop asking for the Social Security card.
A child with a significant narrowing of the esophagus required biweekly dilation—an intensive procedure involving passing a tube down her throat and into her esophagus. The child was scheduled for surgery at Boston Children’s to correct the problem, but her surgery was delayed for months. The lead surgeon had to be screened and enrolled in the child’s state first—a requirement that was not explained until days before the patient’s scheduled arrival in Boston. The patient eventually had her surgery there, but she had to endure additional uncomfortable dilations in her home state while she waited.
Pediatric healthcare organizations that frequently treat children with medical complexity should strongly consider proactively enrolling their providers in the Medicaid programs for neighboring states. By taking the initiative to adequately research and execute a successful out-of-state enrollment strategy, these organizations can reduce their administrative headaches, avoid potential bad debt, and effectively treat this population of patients as quickly as possible.
TractManager’s Provider Management services facilitate the enrollment process. Our enrollment experts are extremely knowledgeable about the states’ varying enrollment requirements, having processed applications for all 50 states. Our enrollment team is well-equipped to enroll your out-of-state Medicaid providers quickly, accurately, and compliantly.
AAP News & Journals – Pediatrics – Recognition and Management of Medical Complexity
Medicaid and CHIP Payment and Access Commission (MACPAC). 2018. State Medicaid payment policies for inpatient hospital services. December 2018. Washington, DC: MACPAC.
U.S. Government Accountability Office (GAO). 2019. CMS oversight should ensure state implementation of screening and enrollment requirements. Report no. GAO-20-8. Washington, DC: GAO.
Hawaii Medical Services Association Provider Resource Center (HMSA). 2018. QUEST integration—Medicaid provider enrollment requirements by state as of March 1, 2016. Honolulu, HI: HMSA.
California Department of Health Care Services (DHCS). 2020. Provider enrollment. Sacramento, CA: DHCS.
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