Non-Medicaid Providers May Now Collect Copays for Dual Covered Patients

Molly PereiraFeatured News

In the past, two conflicting sections of state law have disagreed on whether a copay or deductible associated with a dually covered patient’s primary insurance plan could be collected from Medicaid patients. If a dentist did not collect a required private plan copay, he/she could be subject to insurance fraud penalties. If a dentist did collect the required private plan copay, he/she could be subject to fines under a section of state law that prohibits providers from collecting any fee from a Medicaid patient for a covered service. Given this catch-22 in state law and potential legal liability it created, many dentists were hesitant to see patients who had coverage both under a private dental plan and Medicaid.

However, this past legislative session, the CDA was successful in improving the legal environment for these patients and the dentists who treat them. The state Medicaid program recently issued a bulletin that clearly allows a non-Medicaid provider to collect a required copay or deductible from a patient who has dual coverage (both Medicaid and a private dental plan) in order to bill the private plan for a covered service. Before collecting the copay or deductible, the patient must sign a voluntary informed consent agreeing to the cost sharing. These dual covered patients may not be balance billed for any amount the private plan does not pay, unless the service provided is a noncovered benefit under the Medicaid dental plan. Read the full Medicaid policy.

Again, this policy applies only to dentists who are not enrolled as Medicaid providers. This new Medicaid policy does not address collection of copays and deductibles by a dentist that participates in the Medicaid network. This issue will be addressed separately in coming months, and the CDA hopes to work with the state to arrange direct reimbursement of the provider for these copays in the future.