Chapter 13 Medicaid and other state programs

The time limit for submitting a Medicaid claim varies from ___ from the date the service is rendered.

2 months to 1 year (answer will vary, depending on state laws).

coinsurance

A cost-sharing requirement under a health insurance policy providing that the insured will assume a percentage of the costs for covered services . For Medicare, after application of the yearly cash deductible, the portion of the reasonable charges (20%) for which the beneficiary is responsible. In the Medicaid Qualified Medicare Beneficiary program, the amount of payment that is above the rate that Medicare pays for medical services. The state assumes responsibility for payment of this amount.

Medicaid (MCD)

A federally aided, state-operated and state-administered program that provides medical benefits for certain low-income persons in need of health and medical care. California's Medicaid program is known as Medi-Cal.

copayment

A patient's payment (e.g., 20% of the bill or flat fee of $10 per visit) of a portion of the cost at the time the services is rendered; sometimes referred to as coinsurance. In the Medicaid program, a required specific dollar amount that must be collected at each office visit for medical services received by an individual. Different copayment amounts may be set for each patient type and for certain medical procedures.

recipient

A person certified by the local welfare department to receive the benefits of Medicaid under one of the specific aid categories; an individual certified to receive Medicare benefits.

supplemental security income (SSI)

A program of income support for low-income aged, blind, and disabled persons established by Title XVI of the Social Security Act.

State Children's Health Insurance Program (SCHIP)

A state child health program that operates with federal grant support under Title V of the social security act. In some states this program may be known as Maternal and Child Health Program (MCHP) or Children's Special Health Care Services (CSHCS)

Maternal and Child Health Program (MCHP)

A state service organization to assist children younger than 21 years of age who have conditions leading to health problems.

Categorically needy

Aged, blind, or disabled individuals or families and children who meet financial eligibility requirements for Aid to Families with Dependent Children (AFDC), Supplemental Security Income (SSI) or optional state supplement.

fiscal agent

An organization that processes claims for a government program; insurance carrier handling claims form physicians and other suppliers of service for Medicare Part B; also referred to as Medicare administrative contractor (MAC), formerly fiscal intermediary.

The only state without a Medicaid program that is similar to those existing in other states that has an alternative prepaid medical assistance program is ___.

Arizona.

Your Medicaid patient also has TRICARE. What billing procedure do you follow? Be exact in your steps for a dependent of an active military person.

Bill TRICARE first. Bill Medicaid second and attach a Remittance Advice, Explanation of Benefits, or check voucher from TRICARE to the billing form.

The insurance claim form for submitting Medicaid claims in all states is ___.

CMS-1500 (08-05) Health Insurance Claim Form.

Medi-Cal

California's version of the nationwide program known as Medicaid.

DEFRA

Deficit Reduction Act of 1984

EPSDT

Early and Periodic Screening, Diagnosis, and Treatment

The name of the program for the prevention, early detection, and treatment of conditions of children receiving welfare is known as ___. It is abbreviated as

Early and Periodic Screening, Diagnosis, and Treatment. EPSDT.

There is only one type of copayment requirement in the Medicaid program.

False

FPL

Federal Poverty Level

MCHP

Maternal and Child Health Programs

MQMB

Medicaid Qualified Medicare Beneficiary

Name the three aid programs for low-income Medicare patients.

Medicaid Qualified Medicare Beneficiary Program, Specified Low-Income Medicare Beneficiary Program, Qualifying Individuals Program

Medicare beneficiaries that are disabled but have annual incomes below the federal poverty level may be eligible for ___.

Medicaid Qualified Medicare Beneficiary Program. Qualifying Individuals Program. Specified Low-Income Medicare Beneficiary Program.

MN

Medically needy

OBRA

Omnibus Budget Reconciliation Act

OOY claims

Over one year claims

medically needy (MN)

Persons in need of financial assistance or whose income and resources will not allow them to pay for the cost of medical care; also called medically indigent in some states.

covered services

Specific services and supplies for which Medicaid will provide reimbursement; these consist of a combination of mandatory and optional services stated in the plan.

SLMB

Specified Low Income Medicare Beneficiary

SCHIP means ___ and MCHP means ___ and covers children of what age group?

State Children's Health Insurance Program; Maternal and Child Health Program; Younger than 21 years.

SSI

Supplemental Security Income

TEFRA

Tax Equity and Fiscal Responsibility Act

TANF

Temporary Assistance for Needy Families

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The EPSDT program covers screening and diagnostic services to determine physical or mental defects in recipients younger than 21 years of age and health care, treatment, and other measures to correct or ameliorate any defects and chronic condition discovered. In New York, this is called the Child Health Assurance Program (CHAP).

share of cost

The amount the patient must pay each month before he or she can be eligible for Medicaid; also known as liability or spend down.

prior approval

The evaluation of a provider request for a specific service to determine the medical necessity and appropriateness of the care requested for a patient. Also called prior authorization in some states.

A state agency that investigates complaints of mistreatment in long-term care facilities is the Medicaid Fraud Control Unit (MFCU).

True

Cerebral palsy is a condition that qualifies a child for benefits under the Maternal and Child Health Program.

True

Providers must enroll for participation in the Medicaid program with the fiscal agent for their region.

True

When filing a claim for a Medicaid managed care patient, transmit the claim to the managed care organization and not the Medicaid fiscal agent.

True

Five categories of adjudicated claims that may appear on a Medicaid remittance advice document are:

adjustments approvals denials suspends audit/refund transactions

Medicaid is not an insurance program. It is a/an ___ program.

assistance

Name two broad classifications of people eligible for Medicaid assistance.

categorically needy, medically needy

Because the federal government sets minimum requirements, states are free to enhance the Medicaid program. Name two ways in which Medicaid programs vary from state to state.

coverage benefits

Your Medicaid patient seen today needs long-term hemodialysis services. You telephone for authorization to get verbal approval. Four important items to obtain are:

date of authorization name of the person who provided authorization approximate time of day authorization was given verbal number given by field office

In all other states, the program is known as medicaid, but in california the program is called

medi-cal

When professional services are rendered, the Medicaid identification card or electronic verification must show eligibility for ___.

month of service.

When a Medicaid patient requires a piece of durable medical equipment, the physician must ___.

obtain prior authorization, preferably written.

POS machine

point of service machine

QMB

qualified Medicare beneficiary

QI program

qualifying individuals program

Name three levels of Medicaid appeals.

regional fiscal intermediary or Medicaid bureau Department of Social Welfare or Human Services appellate court

RA

remittance advice

SCHIP

state children's health insurance program

Medicaid is administered by ___ with partial ___ funding.

state governments federal

When a Medicaid patient is injured in an automobile accident and the car has liability insurance, this involves a third-party payer so the insurance claim is sent to ___.

the automobile insurance carrier.

A patient's Medicaid eligibility may be verified by ___.

touch-tone telephone. modem. special Medicaid terminal equipment.