Is there a manual to read up about Medicaid rules and regulations?

2 answers | Last updated: Nov 21, 2016
A fellow caregiver asked...

Is there a manual to read up about Medicaid rules and regulations? There are more opinions from people. I would like to be able to read the regulations myself.

Expert Answers

The problem is that Medicaid is slightly different in every state -- different rules for eligibility, coverage of different kinds of care, different copayments. So, there is no single federal Medicaid manual that can explain the specific rules and regulations that apply in your state. One Medicaid pamphlet, available through the Web site of the federal Center for Medicare and Medicaid Services (CMS), explains general Medicaid rules. It's called Medicaid at a Glance and gives you an overview of the system. You can also go to the general Medicaid information page on the CMS Web site and look for information about specific Medicaid issues. But to get specific information about how Medicaid actually works where you live, you need to go through the Medicaid program for your state. You can find the Web site of your state's Medicaid program by going to any Internet search engine and entering the word Medicaid and the name of your state. Once you reach your state's Medicaid program Web site, it may have a general manual -- either online or a print version you can order -- of its rules and regulations. And you can always call their state office with specific questions.

Community Answers

Gregmcmorrow answered...

I applaud you for wanting to investigate how medicaid works, but at the risk of breaking your spirit, you need to understand how all insurers, public or private approach matters.

Most patients believe that it is possible to "check to see if something is covered" but if you were to contact the insurer, you would receive a carefully worded response. The first part of the response will seem to answer the question- -is it a covered benefit? While a "yes" answer would seem to bring closure, it really does not.

This is because Medicaid/Medi-Cal plans always include the statement "based upon medical necessity". So even though your doctor may have written a prescription, that does not establish medical necessity. Medical necessity introduces additional criteria that makes answering the real question: "can I use my insurance to obtain the services?

This is relevant to the question regarding a "medicaid manual" in that if one is located, it will also have this general caveat.