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Medicaid recipients not allowed to get out-of-pocket care

"It is actually illegal for that provider to take private pay or out-of-pocket payment from a Medicaid member," a licensed professional counselor in Arvada said.

DENVER — Getting an out-of-network medical bill could set you back thousands of dollars.

A Longmont mother wants to pay out-of-pocket and, essentially, out-of-network for care for her daughter, who is on Medicaid.

"I was told by a couple [of doctors] that it was, actually, insurance fraud to try to make an appointment with someone who didn't take Medicaid," said mother Mary Keiran. "Quite frankly, I was horrified to find out that we couldn't self-pay."

Medicaid is for people with low incomes, but also, people with certain disabilities like Keiran's adult daughter.

She was seeking a dermatologist for her daughter when she found out she was asking the doctor to commit a crime.

"You have to go to someone that takes Medicaid. You cannot go to someone else. I don't understand," said Keiran. "If you can't find a particular provider for something, a service that you need or want, why can't you self-pay for that service?"

"It is actually illegal for that provider to take private pay or out-of-pocket payment from a Medicaid member," said Sybil Cummin, a licensed professional counselor in Arvada.

Cummin accepts Medicaid.

"A 50-minute counseling session that is covered by Medicaid, it is illegal for a provider who does not accept Medicaid to accept private pay from that client," said Cummin.

"It was brought about to protect Medicaid members from being taken advantage of by some providers for collecting payments out-of-pocket," said Marc Williams, spokesman for the Colorado Department of Public Health Care and Financing.

Williams said the law goes back to a bill the state legislature passed in 2006.

"It's understandable why this may not make sense to people," said Williams. "Our preference, frankly, would be for providers to enroll in Medicaid."

Medicaid providers have had repeated issues in the last few months.

RELATED: Why some Medicaid providers in Colorado aren't getting paid

Late last year, 199 Medicaid providers were billed to reimburse one of the state's Medicaid networks for services the providers say they provided. After reporting by 9NEWS and The Colorado Sun, the reimbursement bills went away.

Earlier this year, Medicaid providers reported not getting paid for services.

Providers considered leaving Medicaid as a result of these issues.

"Medicaid members might be searching for a therapist and they may be put on a waitlist for six months. And then in that six months, their mental health will decline or they just give up and they're not going to seek the services they need," said Cummin. "There's a pretty huge disparity from what therapists get paid out-of-pocket than what they get paid from Medicaid."

"It's very, very difficult to find providers within the Medicaid network," said Keiran. "In the services that my daughter has received, Medicaid has been amazing."

Keiran would like the system to work just like private insurance, where you can choose to go to an out-of-network provider and pay.

"I don't know how to make a change, but if we don't talk about it, it'll never start," said Keiran.

RELATED: Providers say surprise bills from Colorado Medicaid group could impact patient care

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