Medicaid Balanced Billing: A Medicaid Approved Provider Cannot Demand More Money Than Medicaid Pays

HNWMedicaid Eligibility and Asset Protection Planning

Medicaid costsBalance billing by Medicaid providers is clearly prohibited by both state and federal law. Under 42 U.S.C. § 1396u-2:

Each Medicaid managed care organization shall provide that an individual eligible for medical assistance under the State plan under this title [42 USCS §§ 1396 et seq.] who is enrolled with the organization may not be held liable . . . (B) for services provided to the individual — (i) in the event of the organization failing to receive payment from the State for such services; or (ii) in the event of a health care provider with a contractual, referral, or other arrangement with the organization failing to receive payment from the State or the organization for such services

Federal law requires that “the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or co-payment required by the plan to be paid by the individual.”  42 C.F.R. § 447.15.

Federal law also protects enrollees from liability for payment of covered services provided to the enrollee.  See 42 C.F.R. § 438.106(b).

This rule is incorporated into New Jersey law under N.J.S.A. § 30:4D-6, which states that “every provider making a claim for payment pursuant to this act shall certify in writing on the claim submitted that no additional amount will be charged to the recipient, the recipient’s family, the recipient’s representative or others on the recipient’s behalf for the services, goods, and supplies furnished pursuant to this act.”  N.J.S.A. § 30:4D-6(c).  Additionally, N.J.A.C. § 10:74-8.7(a).

Therefore, Medicaid approved providers cannot seek payment from Medicaid beneficiaries for services rendered that were not paid for by the state Medicaid program.

To discuss your NJ Medicaid matter, please contact Fredrick P. Niemann, Esq. toll-free at (855) 376-5291 or email him at

Please ask us about our video conferencing or telephone consultations if you are unable to come to our office.

By Fredrick P. Niemann, Esq. of Hanlon Niemann & Wright, a Freehold Township, Monmouth County, NJ Medicaid Attorney

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