Medicaid’s Integrated Model – 2025 Overview

Medicaid’s integrated care efforts in 2025 are increasingly focused on aligning Medicare and Medicaid services for individuals eligible for both—commonly known as dual eligibles. A growing number of states now offer Fully Integrated Dual Eligible Special Needs Plans (FIDE-SNPs) and Highly Integrated D-SNPs, which coordinate both programs under one plan to reduce fragmentation and improve outcomes. Enrollment in FIDE-SNPs is now required to include alignment of Medicare and Medicaid plans, with this standard rolling out more broadly in 2025.

Parallel to plan-level integration, new models like the Innovation in Behavioral Health (IBH) Model are taking root. Launching in early 2025 across states including Michigan, New York, Oklahoma, and South Carolina, this CMS-led initiative emphasizes integrated care for adults with serious behavioral health needs—bridging Medicaid and Medicare services through coordinated behavioral and physical health care delivery.Complementing these are longstanding programs like PACE (Program of All-Inclusive Care for the Elderly), which offers a comprehensive blend of medical and social services under one roof, helping seniors with dual eligibility remain in their communities longer.

What Are Types of Provider Relationships with Medicaid?

Medicaid providers can establish different types of relationships with state Medicaid programs depending on their role, services, and the agreements they enter into. Unlike Medicare, Medicaid is state-administered, so details may vary, but most relationships fall into the following categories:

Enrolled (Participating) Providers

⦁ Providers who complete the state’s Medicaid enrollment process and are credentialed to deliver covered services.
⦁ They agree to accept Medicaid reimbursement rates as payment in full (plus any applicable copays).
⦁ This is the most common relationship.

Managed Care Network Providers
⦁ Many states contract with Managed Care Organizations (MCOs) to run Medicaid plans.
⦁ Providers must credential both with the state Medicaid agency and with each MCO network to serve enrollees.
⦁ Reimbursement and reporting rules may differ by MCO.

Fee-for-Service (FFS) Providers
⦁ In states or services still operating under traditional Medicaid FFS, providers bill the state directly.
⦁ These providers must still be enrolled but are not tied to managed care contracts.

Out-of-Network / Non-Participating Providers
⦁ Generally, Medicaid does not pay for services from non-enrolled providers, except in emergency situations or when specific waivers apply.
⦁ Patients may face limits if their provider is not part of Medicaid or an MCO network.

Specialty & Waiver Providers
⦁ Certain providers participate under waiver programs (e.g., Home- and Community-Based Services, PACE programs).
⦁ They must meet additional state-specific requirements, such as training, background checks, and site reviews.

Because Medicaid rules differ by state, navigating provider enrollment and maintaining compliance can be complex. That’s why many practices rely on credentialing experts like Preferred MB, who handle Medicaid enrollment, MCO contracting, and waiver program requirements to ensure smooth onboarding and faster reimbursements.

The Medicaid Provider Credentialing Process Overview

Becoming a Medicaid-approved provider requires careful completion of state-specific enrollment and credentialing requirements. While each state administers its own Medicaid program, most follow a similar structure designed to verify qualifications, ensure compliance, and protect patient care standards.
Key Steps in the Medicaid Provider Credentialing Process

Determine Eligibility
⦁ Confirm that your provider type (physician, nurse practitioner, hospital, DME supplier, behavioral health, etc.) is recognized by your state’s Medicaid program.
⦁ Some specialties (e.g., licensed counselors) may not yet be covered in all states.

Obtain an NPI (National Provider Identifier)
⦁ Every provider must first register for an NPI through NPPES.
⦁ The NPI is required for Medicaid billing and electronic claims submission.

Complete State Medicaid Provider Enrollment Application
⦁ Each state requires its own enrollment form (often available online through the state’s Medicaid portal).
⦁ Depending on provider type, you’ll complete forms for individual providers, group practices, or facilities.

Submit Required Documentation
⦁ State license(s) & board certification(s)
⦁ Proof of malpractice insurance
⦁ Tax ID (EIN/SSN) & business registration
⦁ Ownership and disclosure forms
⦁ Site details (for clinics, hospitals, or DME suppliers)

Pay Application Fee (If Applicable)
⦁ Institutional providers (e.g., hospitals, SNFs, home health, DMEPOS) must pay the CMS-set application fee ($730 in 2025) unless granted a waiver.

Screening & Background Checks
⦁ Providers are assigned a risk category (limited, moderate, high) by CMS and the state.
⦁ High-risk providers (e.g., DME suppliers, home health agencies) require fingerprinting, background checks, and site visits.

Verification & Credentialing Review
⦁ The state Medicaid agency or its credentialing contractor verifies all submitted information.
⦁ This step may involve checking CAQH profiles, performing site visits, or validating malpractice history.

Approval & Provider Number Assignment
⦁ Once approved, you are issued a Medicaid Provider Number (sometimes called a PIN or Medicaid ID).
⦁ This number allows you to submit claims and receive reimbursement.

Managed Care Organization (MCO) Credentialing (If Applicable)
⦁ In most states, Medicaid enrollees are served through MCOs.
⦁ Providers must credential separately with each contracted MCO in addition to state enrollment.

Revalidation & Ongoing Compliance
⦁ Providers must revalidate enrollment every 3–5 years, depending on provider type and state requirements.
⦁ Compliance includes updating licenses, certifications, ownership details, and CAQH/PECOS profiles.

Because these steps vary by state and provider type, errors or delays are common. Partnering with credentialing experts like Preferred MB ensures your Medicaid enrollment applications, documentation, and revalidations are completed accurately—speeding up approvals and protecting your practice’s revenue flow.

What Are Specific Requirements for Medicaid Provider Enrollment?

Medicaid provider enrollment ensures that only qualified, compliant professionals and facilities deliver care to beneficiaries. While requirements vary by state, most follow federal CMS guidelines with added state-specific rules.

Core Requirements for Enrollment

National Provider Identifier (NPI)
⦁ Every provider must have an active NPI registered through NPPES.

State Licensure & Certification
⦁ A valid, unrestricted license in the state of practice.
⦁ For facilities, proof of accreditation or state certification (e.g., for SNFs, home health).

Tax Identification Information
⦁ Employer Identification Number (EIN) or Social Security Number (SSN).
⦁ IRS documentation to verify business identity.

Medicare Enrollment (For Some States)
⦁ Many states require certain providers (e.g., DME, labs) to be enrolled with Medicare before Medicaid enrollment.

Ownership & Disclosure Information
⦁ CMS requires completion of ownership/control interest forms to identify any person/entity with 5% or more interest in the business.

Background Screening & Risk Categories
⦁ Providers are assigned a risk level (limited, moderate, or high).
⦁ High-risk providers (DME, home health) require fingerprinting, background checks, and site visits.

Application Fee (Institutional Providers Only)
⦁ $730 fee for 2025 (subject to CMS annual updates).
⦁ Applies to hospitals, SNFs, home health agencies, and other facilities unless exempted.

Malpractice & Liability Insurance
⦁ Proof of active professional liability insurance meeting state minimums.
1. Revalidation & Maintenance
⦁ Providers must revalidate every 3–5 years.
⦁ Continuous updates required for licensure, certification, CAQH profiles, and ownership changes.

Compliance with State Medicaid Rules
⦁ Some states impose additional requirements like mandatory training, site inspections, or enrollment through Managed Care Organizations (MCOs).
With so many requirements, errors can cause costly delays or claim denials. That’s why many providers partner with credentialing specialists like Preferred MB, who ensure Medicaid enrollment applications are complete, accurate, and fully compliant with both CMS and state-specific rules.

The CAQH ProView Connection

Preferred MB is a trusted credentialing service provider dedicated to helping healthcare professionals streamline enrollment, licensing, and verification processes with precision and efficiency. By offering tailored credential management solutions, Preferred MB ensures compliance with industry regulations while significantly reducing administrative workloads. Our reliable and transparent approach not only saves time but also enhances accuracy, giving providers confidence in their practice operations. With Preferred MB, healthcare organizations and professionals can focus more on delivering quality patient care rather than navigating complex paperwork.

Medicaid Online Provider Portals

Medicaid Online Provider Portals are secure platforms designed to simplify access to essential tools and information for healthcare providers. Through these portals, providers can complete credentialing, verify eligibility, submit claims, and track reimbursements with greater efficiency. By reducing paperwork and streamlining communication, Medicaid Online Provider Portals support compliance and enhance accuracy in managing patient services. They serve as a vital resource for providers seeking to save time, improve workflows, and focus more on delivering quality care.

What Are Best Practices for Successful Credentialing with Medicaid?

Successful credentialing with Medicaid requires careful attention to detail, timely submission of documents, and strict adherence to state-specific guidelines. Best practices include maintaining accurate records, regularly updating licensure and certifications, and monitoring revalidation deadlines to avoid disruptions in reimbursement.

 Partnering with a trusted credentialing service provider like Preferred MB can greatly streamline the process, as we specialize in managing paperwork, ensuring compliance, and reducing costly delays. By following these practices and leveraging the expertise of Preferred MB, healthcare providers can achieve smoother Medicaid credentialing and stay focused on delivering quality patient care.

What Are Medicaid Special Considerations for Different Provider Types?

Medicaid has special considerations for different provider types, as requirements can vary based on services offered and patient populations served. For example.

Physicians and Nurse Practitioners
⦁ Must maintain active state licensure and DEA registration where applicable.
⦁ Board certifications and specialty documentation may be required.
⦁ Compliance with Continuing Medical Education (CME) standards is often reviewed.

Behavioral Health Providers
⦁ Additional credentialing steps for psychiatrists, therapists, and counselors.
⦁ Requirements for treatment plan documentation and patient progress notes.
⦁ Supervision documentation if services are rendered by interns or trainees.

Dental and Vision Providers
⦁ State-specific Medicaid rules for covered procedures and age groups.
⦁ Facility compliance with sanitation, safety, and accessibility regulations.
⦁ Accurate coding for preventive vs. specialized services is closely monitored.

Home Health Agencies
⦁ Must demonstrate compliance with Medicare/Medicaid Conditions of Participation.
⦁ Site inspections and surveys are commonly required for approval.
⦁ Staffing records, including nursing licenses and background checks, are reviewed.

Durable Medical Equipment (DME) Suppliers
⦁ Proof of physical location (not a P.O. Box) is mandatory.
⦁ Adherence to equipment safety and patient instruction standards.
⦁ Medicare accreditation may be required as part of Medicaid enrollment.

Hospitals and Specialty Clinics
⦁ Must maintain Joint Commission or other recognized accreditations.
⦁ Compliance with reporting requirements for quality measures.
⦁ Verification of privileges for employed or affiliated physicians.

How Our Certified Medicaid Credentialing Specialists Accurately Handle Your Medicaid Credentialing
At Preferred MB, our certified Medicaid credentialing specialists bring expertise and precision to every step of the process, ensuring applications are completed correctly the first time. By staying up to date

with state-specific Medicaid requirements, we minimize errors, speed up approvals, and protect providers from costly delays.
With a proven track record of accuracy, Preferred MB handles everything from documentation to compliance verification with unmatched attention to detail. Our specialists work closely with providers, offering guidance and support that simplifies Medicaid credentialing while allowing healthcare professionals to focus on delivering quality care.