Last year, the Medicaid and CHIP Payment and Access Commission (MACPAC) reported that almost 90% of children’s hospitals serve out-of-state Medicaid patients. However, despite this fact, care from out-of-state hospitals continues to be inaccessible to many children with complex medical conditions. The MACPAC states that in most cases, Medicaid enrollees receive medical services within their state of residence, but some receive care out-of-state under certain circumstances. As current Medicaid regulations stand, states must provide out-of-state coverage when: (1) there is a medical emergency; (2) the beneficiary’s health would be endangered if required to travel to the state of residence; (3) services or resources are more readily available in another state; or (4) it is in general practice for recipients in a particular locality to use medical resources in another state.
Elizabeth Zakutansky is a three-year-old who was born with a rare genetic condition which causes her to have seizures. For a while, she was receiving treatment at Lurie Children’s Hospital of Chicago (Lurie). Lurie eventually stopped treatment due to Indiana Medicaid paying out-of-state providers significantly less than in state providers. This is the case for many Medicaid programs. Because of this, the family has chosen to pay one of Lurie’s neurologists out-of-pocket for consultations in which the doctor provides detailed instructions for Elizabeth’s care to her pediatrician back home. Stories like this are not too uncommon. For instance, Dr. John Cunningham, a Physician-in-Chief at Comer Children’s Hospital in Chicago, recalled a treatment in which hospital staff removed a brain tumor in a child from Indiana. However, after the surgery, Indiana Medicaid refused a payment deal which resulted in the child having to receive follow-up care within his state of residence.
Kaiser Health News claims that state Medicaid officials argue that their states cannot afford to send children to out-of-state facilities that demand higher payment rates. On the contrary, out-of-state children’s hospitals argue that all they want is for Medicaid to pay them the same as in-state providers. This ongoing debate is where things get complicated. Adding to the mix is that most states have private Medicaid managed-care plans running their programs, and the plans have the power to control which providers a patient can see and how much to pay them. Children’s hospitals across the country also have spoken out about Medicaid barriers to treating out-of-state children. Leaders at the Denver area’s Children’s Hospital Colorado have said that their doctors must obtain separate liability insurance policies in each state each of which has a different policy on covering families’ travel and lodging.
Further, Kaiser Health News states that children’s hospitals across the country have said that getting approval from Medicaid agencies and managed-care plans to treat out-of-state children and negotiating payment often take more time than delivering the care itself. The out-of-state provider and Medicaid program have to arrange individualized case agreements for each patient. In addition, many states require out-of-state providers to undergo provider screening and enrollment, which can be an extensive process. This has caused some providers to raise concerns. Although families do have the option to seek treatment for their child within their state of residence, there are some cases where receiving treatment at an out-of-state facility is more convenient. For instance, perhaps a particular out-of-state clinic has medical staff who are specialized to treat a rare condition. Congress has already taken steps to break these barriers and make out-of-state treatment more accessible for children with complex conditions, but the fight continues to make treatment widely accessible.
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About The Author
Segan Falconer earned a B.A. degree in English from Colorado State University-Pueblo. She is experienced in content writing, grant writing, and press release writing and currently works as the Human Resources Assistant at Voyager Home Health Care.
- Segan Falconer -