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,
- Undocumented aliens
- Persons receiving waiver or hospice services
- Persons with both Medicare and Medicaid (called dually
- Persons with spend-down
- Persons with breast and cervical cancer
- Refugees who do not qualify for any other aid category
The benefit packages associated with Traditional Medicaid
- 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
- 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."
For more information, see the IHCP Provider Manual.