What is Medicaid

Medicaid in the U.S. is a social health care program for families and individuals with low income and resources.

The Health Insurance Association of America describes Medicaid as a “government insurance program for persons of all ages whose income and resources are insufficient to pay for health care.” Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States. It is a means-tested program (testing the individual’s income) that is jointly funded by the state and federal governments and managed by the states, with each state currently having broad leeway to determine who is eligible for its implementation of the program. States are not required to participate in the program, although all currently do. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid. In New York, having a legal immigration status (even before becoming a green card holder) qualifies a person for Medicaid Benefits.

The Patient Protection and Affordable Care Act significantly expanded both eligibility for and federal funding of Medicaid. Under the law as written, all U.S. citizens and legal residents with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. However, the United States Supreme Court ruled in National Federation of Independent Business v. Sebelius in 2012 that states do not have to agree to this expansion in order to continue to receive previously established levels of Medicaid funding, and many states have chosen to continue with pre-ACA funding levels and eligibility standards.

Medicaid Eligibility

As of 2013, Medicaid is a program intended for those with low income, but a low income is not the only requirement to enroll in the program. Eligibility is categorical—that is, to enroll you must be a member of a category defined by statute; some of these categories include low-income children below a certain age, pregnant women, parents of Medicaid-eligible children who meet certain income requirements, and low-income seniors. The details of how each category is defined vary from state to state.

People with disabilities who do not have a work history and who receive SSI (Supplemental Security Income from Social Security) are enrolled in Medicaid as a mechanism – often automatically – to provide them with health insurance. Persons with a disability, including blindness or physical disability, deafness, or mental illness can apply for SSI. However, in order to be enrolled, applicants must prove that they are disabled to the point of being unable to work. In recent years, a substantial liberalization occurred in the field of individual disability income insurance, which provides benefits when an insured person is unable to work because of illness or injury.

Medicaid Fraud and Our Assistance

While Medicaid fraud involves knowingly misrepresenting the truth to obtain unauthorized benefit, abuse includes any practice that is inconsistent with acceptable fiscal, business or medical practices that unnecessarily increase costs. Waste is a related, though somewhat different issue, which encompasses overutilization of resources and inaccurate payments for services, such as unintentional duplicate payments.

Various programs have been developed at both the state and federal levels to prevent, identify and prosecute Medicaid fraud and abuse by providers, patients and insurers. While states have traditionally relied upon the “pay and chase” model, paying Medicaid claims and then trying to recover improper payments, the focus is increasingly on preventing and detecting fraudulent activities early on.

New York has integrated targeted data mining and risk analysis into its fraud-fighting tool box.

In New York, Medicaid Fraud is both federal and state-level crime. New York City Human Resources Administration (NYC HRA) has recently developed and fully equipped a special department of fraud investigators within its Revenue Recovery division to investigate and recover Medicaid and low income insurance premiums from those individuals that they consider having improperly received benefits when having either too high of income, or too much financial resources to have qualified at the time receiving the benefits. Also, some people are found to provide false information on their applications to qualify.

Our firm has successfully assisted hundreds of people in NY and NJ with Medicaid Fraud investigations. In many cases, we were able to close the investigations altogether and prove that our clients were fully eligible. In other cases, we obtained for our clients peaceful settlement agreements without any long term financial nor criminal implications.

Call Law Offices of Marina Shepelsky, P.C. today if you have received any letters from any government agency about Medicaid Fraud investigation and our attorneys will fight for you and your rights. We will shield you with our experience and strategies.
Law Offices of Marina Shepelsky, P.C. – 212-292-9005.