Chapter 15: Medicaid

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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


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