Traditional Medicaid (Fee-for-service)

In Traditional Medicaid, sometimes called fee-for-service (FFS), providers are reimbursed per service. Providers bill the Indiana Health Coverage Programs (IHCP) claims processing contractor, HP, for services rendered to members.

Traditional Medicaid provides coverage for healthcare services rendered to the following eligible groups:

  • Persons in nursing homes and other institutions, such as an intermediate care facility for the intellectually disabled (ICF/ID, formerly ICF/MR)
  • Undocumented aliens
  • Persons receiving waiver or hospice services
  • Persons with both Medicare and Medicaid (called dually eligible)
  • Persons with spend-down
  • Persons with breast and cervical cancer
  • Refugees who do not qualify for any other aid category

Benefit Packages

The benefit packages associated with Traditional Medicaid are:

  • Standard plan - members enrolled in the Traditional Medicaid Standard Plan are eligible for full coverage.
  • Spend-down - members with income in excess of the Traditional Medicaid threshold are enrolled under the spend-down provision. Spend-down is similar to a deductible in that members must incur medical expenses in the amount of their excess income each month before becoming eligible for Traditional Medicaid. The member becomes eligible at the beginning of the month, but payments are subject to reduction based on the amount of spend-down liability remaining for the month.
  • Medicare Savings Program - Federal law requires that state Medicaid programs pay Medicare coinsurance, deductibles, and/or premiums for certain elderly and disabled people through a program called the Medicare Savings Program. These people are designated as either QMB (qualified Medicare beneficiary), SLMB (specified low-income beneficiary) QI (qualified individual) or QDWI (qualified disabled working individual) and must meet the following eligibility criteria to receive assistance with Medicare-related costs:
    • Entitled to Medicare
    • Low income
    • Age 65 years or older, or younger than 65 years old and entitled to Medicare
    • Few personal resources
  • Waiver - Waiver programs cover a variety of home and community-based services (HCBS) not otherwise reimbursed by the IHCP. Waiver programs are available to IHCP-eligible members who require the Level of Care (LOC) services provided in a nursing facility (NF), hospital, or ICF/ID, but choose to remain in the home. Eligibility for all waiver programs requires the following:
    • The member must meet IHCP eligibility guidelines.
    • The member would require institutionalization in the absence of the waiver or other home-based services.
    • Providers must verify member eligibility, and if a member is enrolled in managed care, the member must be disenrolled.
  • Emergency services only (package E) - health coverage for certain members is limited to treatment for medical emergency conditions. These members are in the FFS delivery system only. The Omnibus Budget Reconciliation Act (OBRA) of 1986 defines an emergency medical condition as: "A medical condition of sufficient severity (including severe pain) that the absence of medical attention could result in placing the member's health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any organ or part."

More Information

For more information, see the IHCP Provider Manual.