Insurance for the Medical Office Chapter 13: Medicaid and Other State Programs

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

1. Adjustments 2. Approvals 3. Denials 4. Suspends 5. Audit/refund transactions

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.

1. Bill TRICARE first 2. Bill Medicaid second and attach a Remittance Advice, EOB, or check voucher from TRICARE to the billing form.

Name 2 broad classifications of people eligible for Medicaid assistance.

1. Categorically Needy 2. Medically Needy

Because the federal government sets minimum requirements, states are free to enhance the Medicaid program. Name 2 ways in which Medicaid programs vary from state to state.

1. Coverage 2. Benefits

Your Medicaid patient seen today needs long-term hemodialysis services. You telephone for authorization to get verbal approval. 4 important items to obtain are:

1. Date of Authorization 2. Name of the person who provided authorization 3. Approximate time of day authorization was given 4. Verbal number given by field office

Name the 3 aid programs for low-income Medicare patients.

1. Medicaid Qualified Medicare Beneficiary Program 2. Specified Low-Income Medicare Beneficiary Program 3. Qualifying Individual Program

What are 3 added benefits of VA/Military Health Care?

1. Prosthetics and orthotics 2. Home improvement to improve structural access 3. Automobile adaptions

Name 3 levels of Medicaid appeals.

1. Regional fiscal intermediary or Medicaid bureau 2. Department of Social Welfare or Human Services 3. Appellate Court

The time limit for submitting a Medicaid claim varies from ____________________ to _______________ from the date the service was rendered.

2 Months to 1 Year

The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act are federal legislations passed in

2010

What portion of long-term care does Medicaid pay for?

40% of $357 billion

How much does the federal government pay into Medicaid?

50-74%

Where do Medicaid expenditures go?

68.2% for acute care 28.1% for long-term care 31.1% for payments of MCOs Totaling $438.23 billion

Estate recovery

Allows state to recoup $$ from estate of a person who resided in a nursing facility or medical institution that was supported by Medicaid while in the institution

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

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

Assistance

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

Automobile insurance carrier

Medicaid is available to needy and low-income people such as the

Blind, disabled and aged (65+)

The federal aspects of Medicaid are the responsibility of the

CMS (Centers for Medicare and Medicaid Services)

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

CMS-1500 (02-12) Health Insurance Claim Form

Medicaid eligibility is known as

Categorical eligibility, medically needy eligibility and Medicare-Medicaid dual eligibility

What groups are excluded from Medicaid?

Childless couples and single men

The amount the patient must pay each month before he or she can be eligible for Medicaid is known as

Copayment, spend down, and share of cost

Specific mandatory and optional services and supplies for which Medicaid will provide reimbursement are called

Covered services

Indian Health Services

Direct delivery (176 hospitals) or tribal self determination (518 facilities)

The Medicaid Service for prevention, early detection, and treatment for welfare children is known as

EPSDT (Early and Periodic Screening, Diagnosis and Treatment)

A program that covers screening and diagnostic services to determine physical or mental defects in recipients younger than age 21 and health care, treatment, and other measures to correct defects and chronic conditions is called

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

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

Dual eligibles are

Elderly and persons with disability *The mandatory groups are those receiving SSI payments and those that are a qualified Medicare beneficiary

All Medicaid recipients have the same copayment amounts for receiving medical services.

FALSE

All state Medicaid programs operate with a fee-for-service reimbursement system.

FALSE

Medicaid is available to U.S. Citizens but not to immigrants.

FALSE

Medicaid spend down eligibility is determined annually to find out the patient's monthly copayment amount.

FALSE

Patients receive a Medicaid card annually.

FALSE

The claim for a Medicaid managed care patient should be sent to the Medicaid fiscal agent.

FALSE

The terms copayment and coinsurance have the same meaning.

FALSE

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

FALSE

Title XIX of the Social Security Act became federal law and created Medicaid in 1955.

FALSE

An organization under contract to the State to process claims for a state Medicaid program is known as a ________________ and _______________________.

Fiscal agent; Fiscal intermediary

Basic Maternal and Child Health Program (MCHP) provisions offered in all states include children with

Handicap needs who require orthopedic treatment or plastic surgery

Scope of Medicaid?

Health insurance coverage, assistance to Medicare beneficiaries, long-term care assistance, support for health care system and safety net, state capacity for health coverage

Medicaid

Joint federal-state medical insurance program

Mandatory Categorical Eligibility are:

Low-income families, recipients of SSI, pregnant women and children under age of 6 in household with income less than 133% of federal poverty level, children ages 6-19 in household with income less than 100% of federal poverty level, and wards of state

Medicaid managed care patient claims should be sent to the

Managed care organization and NOT the Medicaid fiscal agent.

To control escalating health care costs by curbing unnecessary emergency department visits and emphasizing preventive care, Medicaid reform has involved

Managed care programs

A state service organization to assist children who have certain kinds of handicaps or conditions that lead to health problems is called

Maternal and Child Health Program and State Children's Health Insurance Program

California's version of the nationwide program known as Medicaid is called

Medi-Cal

In all other states, the program is known as Medicaid, but in California the program is called

Medi-Cal

A federally aided, state-operated and administered program that provides medical benefits for certain low-income persons in need of health and medical care is called

Medicaid

What is the 2nd largest portion of the state budget go towards?

Medicaid

What is the 3rd largest portion of the federal budget go towards?

Medicaid

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

Medicaid Qualified Beneficiary Program

The Federal Emergency Relief Administration made funds available to pay for

Medical expenses of the needy unemployed

Medicaid classifications that contain several basic groups of needy and low-income individuals are _____________________________ and __________________________.

Medically needy groups; Categorically needy groups

SCHIP (State Children's Health Insurance Program)

Meets needs of children in working poor families

Medicaid eligibility must always be checked for the _____________ of service.

Month

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

Month of Service

Means test

Must meet income and asset limits to qualify for Medicaid

Military Health Insurance

NOT VA Benefits TRICARE -Covers active and retired military and retirees/families -Pays for health care in civilian system

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

Obtain prior authorization, preferably written.

State Children's Health Insurance Programs (SCHIPs)

Operate with federal grant support under the Title V of the Social Security Act

Is physical therapy an optional or mandatory benefit for Medicaid?

Optional

Medicaid is the largest health insurance in terms of ____________________________ while Medicare is the largest in terms of _____________________.

Persons served; Money

PCCM (Primary Care Case Management)

Primary care physician receives capitated payment and specialists are paid fee-for-service

The Omnibus Budget Reconciliation Act

Provided assistance for the aged and disabled who are receiving Medicare and whose incomes are below the poverty level

An individual certified by the local welfare department to receive the benefits of Medicaid under one of the specific aid categories is known as a/an

Recipient

Most states have _____________________ for Medicaid payments if a patient requires medical care while out of state

Reciprocity

The effects of Medicaid reform are:

Reduced health disparities Improved access to primary care Decreased unnecessary hospitalization and ER visits

The medically needy aged

Require help in meeting costs of medical care

The Social Security Act of 1935

Set up public assistance programs

The Social Security Act of 1935

Set up the public assistance programs

Spousal impoverishment prevents:

Spouse living at home from being impoverished by spouse residing in nursing facility. Protects home, one care, household goods, burial account and community spouse's income is not counted, up to $109,560 in assets and minimum monthly income of $1,821.25 for community dwelling spouse

SCHIP means __________________________________ and MCHP means __________________________ and covers children of what age group?

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

Medicaid is administered by ________________ with partial __________________ funding.

State Governments; Federal

Medicaid is administered by the

State government with partial federal funding

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

Supplemental Security Income

A Medicaid patient who also has Medicare is sometimes referred to as a crossover case.

TRUE

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

TRUE

All states processing medical claims must bill using the CMS-1500 claim form.

TRUE

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

TRUE

Coinsurance is the portion the patient pays of the Medicare allowed amount.

TRUE

Emergency care and pregnancy services are exempt by law from copayment requirements.

TRUE

Health care reform legislation passed in 2010 affected the Medicaid program by allowing states to expand their programs in 2014.

TRUE

In some states, the phrase prior approval may be referred to as prior authorization.

TRUE

Medicaid is not so much an insurance program as an assistance program.

TRUE

Prior approval is always required when a Medicaid patient requires a hearing aid.

TRUE

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

TRUE

The Tax Equity and Fiscal Responsibility Act established legislation affecting Medicare and Medicaid recipients.

TRUE

The amount a patient must pay each month before he or she can be eligible for Medicaid is called share of cost.

TRUE

The patient's Medicaid card must be checked each time the patient visits the physician's office to verify eligibility for month of service.

TRUE

When Medicaid and a third-party payer cover the patient, Medicaid is always the payer of Last Resort.

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

If a physician accepts Medicaid patients, the physician must accept

The Medicaid-allowed amount

A patient's Medicaid eligibility may be verified by

Touch-tone telephone, Modem, and Special Medicaid terminal equipment

The time limit to appeal a claim varies from state to state, but it's

Usually 30-60 days

Who operated the largest health care system in the United States?

VA

In the Medicaid program, Congress authorized vendor payments for medical care, which are payments from the

Welfare agency directly to the physician