Fundamentals in Healthcare Law Webinar Series - April 20, 2022

1. Fundamentals in Healthcare Law Curriculum
2021 – 2022 WEBINAR SERIES
PA R S O N S B E H L E . C O M
N AT I O N A L E X P E R T I S E . R E G I O N A L L AW F I R M .
Medicaid in Idaho
Wednesday, April 20, 2022

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Legal Disclaimer
This webinar is based on available information as of April 20, 2022, but
everyone must understand that this webinar is not a substitute for legal
advice. This presentation is not intended and will not serve as a
substitute for legal counsel on these issues.

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Presenter
• J. Kevin West
208.562.4908
kwest@parsonsbehle.com

5. AGENDA

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A. Medicaid Basics
• Introduction
• Eligibility
• Benefits
• Reimbursement
• Waivers
B. Idaho Medicaid
• Key laws and regulations
• Healthy connections program
• Audits & enforcement
• Estate planning issues

7. MEDICAID BASICS

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Medicaid Facts
• Enacted in 1965 as Title XIX to the social Security Act
• Originally was intended to assist the very poor in certain narrow
categories
• The passage of ACA in 2010 significantly changed the scope of
Medicaid

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Medicaid Facts
• Medicaid is the largest health program in the U.S in terms of
enrollment. (Medicare is largest in terms of expenditures)
• Medicaid is one of the largest components of most state budgets

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Medicaid Basics
MEDICARE
1. Federal administration
2. Benefits defined by federal law
3. Payment totally federal
4. Elderly
5. Disabled
MEDICAID
1. State administration with
federal oversight
2. Benefits defined by state with
federal minimums
3. State payment; federal match
4. Low income
5. Dependent children
6. Elderly with disabilities

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Medicaid Financing: Federal Matching Funds
• 50% federal match
• 50-60% federal match
• 60-66% federal match
• 66-75% federal match
• 13 states
• 14 states
• 12 states
• 11 states (includes Idaho)
• Federal government pays the applicable Federal Medical assistance
Percentage (FMAP)
• The FMAP is adjusted each year by CMS

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To Qualify for Federal Matching Funds a State Must:
• Designate a “single state agency to mange the program
• Submit a “state plan” or “amendment” to CMS
• Obtain CMS approval of the plan

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Financial Impact
Medicare = 15% of the federal budget
Medicaid = 10% of the federal budget
= ¼ of the entire federal budget
Medicaid pays for 40% of all long term care in the U.S.

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Eligibility
• Restricted to U.S. citizens and “qualified aliens” (except for
emergency services)
• “Categorically needy” (i.e. those who fall below the Federal Poverty
Level (FPL)
◦ Low-income children
◦ Aged, blind or disabled
◦ Pregnant or post partum women
• Medically needy” (i.e., those who exceed the FPL but who have high
medical expenses; “spending down”

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Eligibility
•2022 FPL:
◦$13,590 Single person
◦$18,310 Family of two
◦$27,750 Family of four

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Benefits
• Federal law mandates a minimum set of benefits
◦ These differ for “categorically needy” vs. “medically needy”
◦ States may obtain “waivers” to modify benefits packages

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SCHIP Program
• Provides coverage for low-income children who fall in the coverage
gaps, i.e., their parents are above the FPL, but cannot afford
healthcare for them
• Operates like the Medicaid program

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Reimbursement
• States set their own reimbursement rates (but must be consistent
with federal minimums)
• States may obtain waivers to charge premiums, deductibles, etc.
• Many providers leaving or declining to participate in Medicaid due to
poor reimbursement

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Waivers
• HHS can grant authority to states to modify Medicaid eligibility,
benefits and reimbursement
• Examples: Increased co-pays
Behavioral incentives
Work requirements
Mandatory vs. optional categories of benefits
• States may seek approval to mandate enrollment in a Medicaid
managed care plan

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Medicaid Expansion
• 39 states and the District of Columbia have adopted Medicaid
expansion. (Idaho adopted in 2019, effective in 2020)
• Medicaid expansion=increases pool of eligible people to those who
are to to 138% of the FPL
• Medicaid expansion added more than 12.5 million people to
Medicaid programs nationally
• Added mental health services, prescription drug rebates
• States are lured in with favorable matching rates by the federal
government, which gradually diminishes over time

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Medicaid Expansion
Family Size 2022 FPL 138% of FPL
1 $13,590 $18,755
2 $18,310 $25,270
4 $27,750 $38,295
Eligibility

22. IDAHO MEDICAID

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Idaho Medicaid
1. Key Laws and Regulations
◦ Idaho False Claims Act
◦ Idaho Anti-Kickback Statute
◦ Self-Referral Prohibition
◦ Idaho Fee Splitting Statute
◦ Idaho Medicaid Provider Agreement
2. Healthy Connections Program
3. Audits and Enforcement
4. Estate Planning issues

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Idaho False Claims Act
• Providers who violate may be excluded from the Medicaid program
who submit false claims
• A “false claim” requires intent:
◦ Actual knowledge
◦ Deliberate indifference of truth or falsity
◦ Willful disregard to truth or falsity
IDAPA 16.05.07.08

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Idaho Anti-Kickback Statute
• Idaho healthcare providers may not—
◦ Pay another person or entity for a referral of a patient
◦ Engage in a regular practice of waiving or rebating co-pays or deductibles
• $5,000 fine per incident. (I.C. 41-348)
• Potential violation and termination of the Medicaid Provider
Agreement

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Self-Referral Prohibition
• Federal Stark Law provides standards in determining what is a
prohibited self-referral
• Violation may result in denial of payment of claims for services
IDAPA16.05.07.200.01

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Idaho Fee Splitting Statute
• Physicians and PAs may not divide fees or agree to do so with any
person/entity in return for a referral
• A provider may not give or receive rebates
• Fee splitting is a violation of the Medicaid provider agreement
I.C. 54-1814

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Idaho Medicaid Provider Agreement
• Requires providers to comply with many federal and state statutes,
rules and regulations
◦ Must maintain records for at least 5 years
◦ Must certify that services are
 Medically necessary
 Actually provided
 Provided in accordance with professional standards
• Must verify the eligibility of Medicaid patient and verify enrollment in
Healthy Connections program
• No balance billing—providers must accept Medicaid payment as
payment in full

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Medicaid Reimbursement in Idaho
• Providers are paid the lowest of—
◦ The provider’s actual charge
◦ The Medicaid fee schedule amount, or
◦ The Medicaid allowed amount minus the Medicare payment (for dual eligible
patients)

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Healthy Connection Program
• The primary case management model for Idaho Medicaid
• Certain Medicaid services require a referral from the patient’s
primary care provider (PCP) (services requiring referrals are listed in
the Idaho Medicaid Provider Handbook)
• PCPs must apply to become Healthy Connections providers (the
may only manage a limited number of Healthy Connection patients
• Healthy Connections PCPs are paid on a capitated basis

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Idaho Medicaid—Excluded Services
• Cosmetic Surgery
• Acupuncture
• Naturopathic services
• Experimental and investigational services

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Audits and Enforcement
• All Medicaid providers must be screened in order to participate
• States are required to either create Medicaid Fraud Unit, or contract
with an approved contractor (Idaho has its own MFU)

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Medicaid “Abuse”
Definition: “Provider practices that are inconsistent with sound fiscal
business, child care or medical practices, and result in unnecessary
cost…or result in reimbursement for medically unnecessary services.”
IDAPA 16.05.07.01

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Medicaid Fraud
1. Actual knowledge
2. With deliberate disregard of the truth or falsity, or
3. With reckless disregard of truth or falsity

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Enforcement Tools
1. Denial of reimbursement
2. Recoupment of overpayments
3. Suspension of provider status
4. Suspension of payment
5. Termination of provider agreement
6. Civil monetary penalties
7. Criminal prosecution
8. Reporting to state licensure boards

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Medicaid Audits
• Often conducted on-site
• Providers must provide “immediate access”
• May involve probability sampling and extrapolation
• Hearing and appeals process
• Providers need counsel from the moment of first contact with a
Medicaid investigator (they are not your friend)

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Documentation Requirements
• Medical records must be –
◦ Contemporaneous
◦ Legible
◦ Consistent with professional standards
◦ Maintained for 5 years
IDAPA 16.05.07.101.01

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Access to Provider Records
• Providers must grant “immediate access” to Medicaid or it agents
during business hours and/or provide copies of records within 20
business days
IDAPA 16.05.07.02 and .101
• Failure to do so may result in severe sanctions, including suspension

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Civil Monetary Penalties
• May be assessed against a provider and, an officer, director, owner
or managing employee of the provider
• $1,000 per claim or, if there are multiple penalties, then 10% of the
amount of the claim, whichever is less
• If aggravating factors exist, the penalties may be increased
IDAPA 16.05.07.235-36

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Dual Eligible Patients
• Patients may qualify for both Medicare and Medicaid benefits
• The state must coordinate and integrate benefits with the federal
government
• Patient must enroll with a Medicare Advantage Plan and request a
Medicare/Medicaid Coordinated Plan (MMCP)
• The patient must be at least 21 years of age

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Estate Planning Issues
• Medicaid spend down requirements
• Three-year look back
• Medicaid has power to impose liens on property of the beneficiary, or
to set aside transfers of property made without adequate
consideration

42. Questions?

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Thank You
• J. Kevin West
208.562.4908
kwest@parsonsbehle.com