Access to affordable health care through the Medicaid program is one of the great benefits afforded to most recipients of Supplemental Security Income (SSI). In many states, full Medicaid coverage is often equal to, or even better than, many private health insurance plans, allowing SSI beneficiaries and other Medicaid recipients to effectively manage their illness or disability.
However, many Medicaid recipients don’t realize that their health insurance coverage generally will not provide a full set of benefits should they require care while out of state.
For example, some states may cover only out-of-state emergency room services in life-threatening situations that require immediate care, when there simply isn’t the time for the injured person to return safely to their home state.
Should a beneficiary need to be admitted to a hospital in another state, or if they must receive essential, regular psychiatric care or medications from an out-of-state provider, the home state will not pay for the services through Medicaid. In these situations, a caregiver or other family member is often required to sign an agreement to pay for the services before the person with special needs can receive care.
It may be possible to get preapproved Medicaid coverage at an out-of-state facility, but the patient would need to obtain proper authorization (a time-consuming and complicated process that may conflict with the urgent realities of the treatment program).
Another scenario might be if the care facility is near the border of the Medicaid beneficiary’s home state and also regularly admits other Medicaid patients from the same home state. However, again, pre-authorization would be required to insure coverage.
Know the Rules
Since Medicaid is administered as a joint program between the state and federal governments, each individual state has its own rules regarding out-of-state Medicaid coverage.
If a loved one with special needs is planning to take an out-of-state trip, or if you live near your state border and travel between states for work or recreation, it makes sense to discuss the out-of-state Medicaid rules with a qualified special needs planner who knows your local restrictions. Investing the time now could save you thousands of dollars in medical bills down the road.