M
Definition
The individual enrolled in a Medicaid or health plan who is eligible to receive transportation benefits. While often used interchangeably with "Patient" or "Beneficiary," "Member" is the specific term used by Managed Care Organizations (MCOs) and Brokers to denote enrollment status.
Overview
Why it Matters
In NEMT, you are transporting a "Member" of a plan. If their membership is inactive on the day of service, you will not get paid, even if they are sick and need care.
How it Works
The Broker imports a "Member File" from the State daily. When a trip is booked, the system queries this file to confirm the person is active.
Code Comparison
Comparison: Member vs. Patient
Member: The person’s relationship to the Insurance Company. (Focus: Eligibility).
Patient: The person’s relationship to the Doctor. (Focus: Clinical condition).
Common Questions
- Dual Membership: A member switching from "MCO A" to "MCO B" mid-month. You might bill the wrong plan if you don't re-verify.
- Name Mismatches: The Member is "Jonathan Smith" in the file but goes by "John Smith," causing search failures in the software.
- Search by Member ID (Subscriber ID), not just by Name/DOB, to ensure you have the correct file.
- Always ask, "Have you changed insurance plans recently?" during booking.
Sources
HealthCare.gov - Member Definition