Medicaid is structured as a federal-state partnership

States run Medicaid programs within federal guidelines and have discretion over who is covered, what services are covered, how health care is delivered, and how physicians and hospitals are paid. States can also get Section 1115 exemptions to test and implement techniques that aren't required by federal law but that the Secretary of HHS thinks are necessary to achieve the program's goals. As a result of this flexibility, state Medicaid systems differ significantly.

The Medicaid entitlement is predicated on two guarantees: first, that all Americans who fulfill Medicaid eligibility standards would be covered, and second, that states would receive federal matching funds for qualifying services delivered to eligible enrollees without a limitation. A formula in the legislation determines the match rate for most Medicaid members, which must be at least 50%, and includes a larger federal match rate for poorer states (Figure 2).

Sometimes individuals try and cheat the system by lying on their Medicaid applications. If they get caught, they will need a competent attorney who is knowledgeable in this area of criminal defense.

Medicaid coverage has evolved over time

Medicaid eligibility for parents, children, the impoverished aged, blind, and individuals with disabilities was related to financial assistance (either Aid to Families with Dependent Children (AFDC) or federal Supplemental Security Income (SSI) commencing in 1972) under the original 1965 Medicaid statute. States may choose to provide coverage at income levels higher than those eligible for financial assistance. Congress has gradually increased federal minimum standards and provided states with more coverage alternatives, particularly for children, pregnant women, and individuals with disabilities. Congress also mandated that Medicaid assist low-income Medicare beneficiaries with premiums and cost-sharing, as well as allowing states to offer a “buy-in” option to Medicaid for working people with disabilities. In 1996, the relationship between Medicaid eligibility and poverty was severed, and in 1997, the Children's Health Insurance Program (CHIP) was established to cover low-income children above the Medicaid cut-off with an improved federal match rate. States sponsored outreach efforts and streamlined enrollment procedures to enroll eligible children in both Medicaid and CHIP for the first time after these legislative changes. Children's Medicaid expansions signaled the start of subsequent revisions that redefined Medicaid as an income-based healthcare program.

Medicaid Fraud Can Be Committed On Various Levels

Medicaid fraud committed by individuals may be termed as “welfare fraud”, while Medicaid Fraud committed by institutions is sometimes referred to as “Healthcare Fraud”.

If Medicaid or Medicare Fraud is discovered by an individual working at the institution where it is going on, that individual may collect a reward for reporting the fraud. The way it is reported is through an attorney who files a Qui Tam Lawsuit on the part of the government.

Fraud committed by individuals is usually relatively small in scope, while fraud committed by institutions can range in millions of dollars. Fraud committed by individuals is usually handled by the local Bureau Of Fraud Investigation if it occurs in NYC. When this happens, the individual suspected of the fraud is sent a letter from the NYC HRA (Human Resource Administration) asking them to come in for an interview. If you receive a letter from the HRA, you should immediately look into speaking to a Medicaid Fraud Attorney to protect your rights.