Chapter 15: Medicaid
States that opt to include a medically needy eligibility group in the Medicaid program are required to include certain children who are under the age of ___ and who are full-time students.
21
How often should providers verify patient's Medicaid eligibility?
At each encounter
Families who meet states' Temporary Assistance for Needy Families (TANF); pregnant women and children under age 6 whose family income is at or below 133% of the federal poverty level, caretakers, supplemental security income recipients (SSI)
Catagorically Needy
When an individual has both plans
Medi-Medi
Government benefit program specifically designed for low income individuals
Medicaid
Sent to the provider which contains the current status of all claims (including adjusted and voided claims)
Medicaid remittance
Qualified persons who may have too much income to qualify under the catagorically needy; allows individuals to "spend down" to Medicaid eligibility by incurring medical and/or remedial care expenses to offset their excess income; families pay monthly premiums in an amount equal to the difference between family income and the income eligibility standard
Medically Needy
When an individual has both plans, covered services are paid by ____________________, and _______________ is always the 'payer of last resort."
Medicare, Medicaid
Which is considered a mandatory Medicaid service that states must offer to receive federal matching funds?
Preauthorized services
States pay Medicare Part A premiums for certain disabled individuals who lose Medicare coverage because of work
Qualified Working Disabled Individuals (QWDI)
State pays Medicare Part B premiums for individuals with incomes between 120 percent and 135 percent of the federal poverty level
Qualifying Individual (QI)
Qualified Medicare Beneficiaries (QMB) - states pay Medicare premiums, deductibles, and coinsurance amounts for individuals whose income is at or below 100 percent of the federal poverty level and whose resources are at or below twice the standard allowed under SSI
Special groups
State pays Medicare Part B premiums for individuals with incomes between 100 percent and 120 percent of the federal poverty level
Specified Low-Income Medicare Beneficiary (SLMB)
Allows states to create or expand existing insurance programs; provides more federal funds to states for the purpose of expanding Medicaid eligibility to include a greater number of children who are currently uninsured
State Children's Health Insurance Program
Which requirements are used to determine Medicaid eligibility for mandatory categorically needy eligibility groups?
Temporary Assistance for Needy Families (TANF)
Which is considered a voided claim?
a claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider
One way federal government verifies receipt of Medicaid services by a patient is by use of
a monthly survey sent to a sample of Medicaid recipients requesting verification
Medicaid is jointly funded by federal and state governments, and each state
administers its own Medicaid program
Which is subject to Medicaid preauthorization guidelines?
any extension of inpatient acute care hospital days
The Temporary Assistance to Needy Families (TANF) program provides
cash assistance on a limited-time basis for children deprived of support
Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary, which means the services are
consistent with the patient's symptoms, diagnosis, condition, or injury
Individuals who are eligible for both Medicare and Medicaid coverage are called
dual eligibles
State legislatures may change Medicaid eligibility requirements
during the year, sometimes more than once
Which services are exempt from Medicaid copayments?
family planning services
Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services are offered for which Medicaid-enrolled population?
individuals under age 21
To receive matching funds through Medicaid, states must offer what coverage?
inpatient hospital services
Medicaid policies for eligibility are complex and vary among states; thus, a person who is eligible for Medicaid in one state
may not be eligible in another state
Programs of All-Inclusive Care for the Elderly (PACE) work to limit out-of-pocket costs to beneficiaries by
not applying deductibles, copayments, and other cost-sharing
A primary care provider in a Medicaid primary care case management (PCCM) plan differs from an HMO primary care provider in that the Medicaid primary care provider is
not at risk for the cost of care provided
When a patient has Medicaid coverage in addition to other, third-party payer coverage, Medicaid is always considered the
payer of last resort
An individual whose income is at or below 100 percent of the federal poverty level (FPL) and has resources at or below twice the standard allowed under the SSI program may receive assistance from Medicaid to pay for Medicare premiums, deductibles, and coinsurance amounts as a
qualified Medicare beneficiary (QMB)
When a patient has become retroactively eligible for Medicaid benefits, any payments made by the patient during the retroactive period must be
refunded to the patient by the practice
A Medicaid card issued for the "unborn child of ...." is good for
services that promote the life and health of the unborn child
A Medicaid voided claim
should not have been paid originally
What is included in a couple's combined resources, according to the Spousal Impoverishment Protection legislation?
summer home
Safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services
surveillance and utilization review subsystem (SURS)
States pay health care providers on a fee-for-service basis or Medicaid services using prepayment arrangements
vendor payment program
One that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made to the provider
voided claim
