Purpose
To outline the Department's policy on charging a fee to Health First Colorado (Colorado's Medicaid program) members or holding them financially liable for missed or canceled appointments.
Background
The Department has received questions from both members and providers regarding a provider's ability to charge fees for missed (or no show) appointments. While missed appointments can result in administrative and cost burden to practices, charging a fee to Health First Colorado members who do not have other health plan coverage is not permitted. Fees may be charged, in some circumstances, to Health First Colorado members who have Medicare or a commercial health insurance plan as the primary payer.
Policy
Federal and state policies prohibit charging Medicaid members for missed or canceled appointments. Similarly, providers cannot bill Medicaid members for scheduling appointments or ask members to sign forms accepting financial liability for missed appointments.
Federal statutes and regulations limit member payments under Medicaid to state-defined cost-sharing arrangements (42 U.S.C. § 1396a (a)(14)). Colorado Medical Assistance Program cost-sharing arrangements are limited to established co-pays for services received. Several categories of Medicaid members, e.g. pregnant women, members receiving behavioral health services, and children under age 19, have no cost-sharing requirements.
In addition, federal regulations provide that state Medicaid agencies must limit provider participation to those who will accept Medicaid reimbursement as payment in full (42 C.F.R. § 447.15).
The Centers for Medicare & Medicaid Services (CMS) has consistently advised that, based on its interpretation of these federal statutes and regulations, Medicaid members must not be charged for missed or canceled appointments. Current Medicaid policy does not allow for billing beneficiaries for missed appointments, in part, because if no service was delivered, no reimbursement is available. In addition, missed appointments are not a distinct, reimbursable Medicaid service, but are considered a part of providers' overall cost of doing business. This policy was articulated at least twenty years ago and reconfirmed by CMS in 2015.
Several years ago, Medicare policy changed to permit billing clients for missed appointments under certain circumstances. This policy states that a provider may assess a missed appointment fee to Medicare patients as long as the fee is applied in the same way as to other patients in a practice, and patients are notified of the practice's criteria for missed appointment fees in advance (i.e. before a fee is assessed). This Medicare policy shift did not alter the long-standing policy applicable to individuals with Medicaid only.
Individuals with both Medicare and Health First Colorado (Medicaid) agree to follow the policies of their respective health plans, therefore, patients with both Medicare and Health First Colorado may be assessed a missed appointment fee by a Medicare-enrolled practice under the circumstances described above. The same policy applies to people with commercial insurance and Health First Colorado coverage. People who have commercial insurance must agree to abide by their plan's policies and procedures, and that would include any fees assessed for missed appointments.
Health First Colorado's policy on billing members for missed appointments is articulated in the Policy Statements section of the Billing Manuals web page.
Health First Colorado Members with questions about this policy should call the Member Contact Center at 1-800-221-3943.