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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 with dependent 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 actually administer the program, decide (for the most part) who can provide medical care, and reimburse PAs and other health care professionals for their services.
PA Coverage
Unlike the Medicare program, which has federal laws mandating the coverage of medical services provided by PAs, each state can determine whether PAs are eligible professionals under its Medicaid program. Currently, all 50 states cover medical services provided by PAs in their fee-for-service or managed care plans at either the same or a lower rate than that paid to physicians. States that cover medical services provided by PAs vary in how they want PAs to identify those services within the Medicaid program. 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 or are required to use a specific fee schedule. PAs should check with the Provider Enrollment or Provider Relations Department of their state Medicaid office to determine the registration process (if any) and the billing procedures.
View detailed information on your state's policy on Medicaid coverage for PAs in our State Medicaid Profiles.
Trends
Because of increasing health care costs, states are finding it difficult to pay for their Medicaid programs. In many states, Medicaid expenditures are the fastest growing part of their budgets. To respond to these cost pressures, states will increasingly look for ways to slow the rate of growth in their Medicaid programs. Some of the methods may include freezing enrollment, reducing available services, tightening eligibility rules to decrease the number of citizens that quality for various Medicaid programs, reducing payments to health care professionals, and increasing the required cost-sharing payments from Medicaid beneficiaries.
A problem area has surfaced in some states regarding the assignment of Medicaid beneficiaries to primary care providers (PCPs). Some states, as they move toward integrating managed care concepts into their Medicaid programs, have required that Medicaid enrollees be assigned to a particular PCP. The PCP is permitted to enroll a fixed number of patients (often ranging from 1,500 to 2,500 patients per provider). Since PAs are not automatically defined as primary care providers, state Medicaid programs may fail to recognize the ability of PAs to treat patients and neglect to allocate additional patients to the practice.
