MBC105 Chapter 8: Understanding Medicaid Exam

Which of the following third party payers are primary to Medicaid?

1. Court-ordered health insurance by noncustodial parent 2. Employment-related health insurance 3. Long-term care insurance 4. Medicare and/or other state or federal programs (unless specifically excluded by federal statute)

What terms describe the elderly or disabled individuals who are poor and who are covered under both Medicaid and Medicare? (Select all that apply.)

1. Dual eligibles 2. Medi-Medi Also referred to as care/caid

Which of the following are examples of third parties that may be liable to pay for services before Medicaid? (Select all that apply.)

1. Medicare 2. Employment-related (group) health insurance 3. Long-term care insurance 4. Workers' compensation

Identify the following common responsibilities of a Medicaid contractor. Select all that apply.

1. Process claims 2. Provide information for healthcare providers for the particular government program involved 3. Generate guidelines for providers to facilitate the claims process 4. Answer beneficiary questions about benefits, claims processing, appeals, and the explanation of benefits (remittance advice [RA]) document

As a general rule, Medicaid only pays for procedures or services that are determined to be medically necessary, which means that the procedure or service must be: (Check all that apply)

1. consistent with the diagnosis 2. performed at the proper level 3. provided in the most appropriate setting

Choose 3 types of healthcare providers that may require a copayment. Select all that apply.

1. podiatrists 2. chiropractors 3. dentists

What should the provider do if a patient insists on being treated for a particular noncovered service?

Ask the patient to sign a waiver stating that the service is not covered by Medicaid and the patient acknowledges responsibility for payment.

Which of the following does NOT constitute Medicaid fraud?

Billing for all covered medical services performed

What type of guidelines does the federal government establish for Medicaid eligibility?

Broad

Which form is the universal claim form accepted by Medicaid contractors in most states?

CMS-1500

A relatively new state option that provides individuals with disabilities who are eligible for nursing homes and other institutional settings with options to receive community-based services.

Community First Choice Option

What term describes the method of payment in which the state Medicaid agency must pay the difference between the third party's payment obligation and the amount the provider is entitled to under Medicaid?

Cost avoiding

An electronic data interchange (EDI) and a point-of-sale (POS) device are the same method of verifying eligibility.

False

Generally, Medicaid recipients receive a new Medicaid card on a yearly basis.

False

If a practice has access to an AVR system of eligibility verification, only one staff member should be trained how to use it correctly and designated to be in charge of patient verification.

False

Medicaid provides medical assistance for all poor persons.

False

Medicaid, by law, always pays first when the patient has OHI.

False

Once prior approval for a product, service, or procedure has been obtained, a Medicaid claim cannot be denied.

False

Physicians cannot limit the number of Medicaid patients they accept.

False

Providers participating in Medicaid may accept the partial Medicaid reimbursement amount and then can bill the patient for the difference.

False

Qualified Medicare Beneficiaries have no income requirements to meet in order to qualify for Medicaid assistance.

False

State participation in Medicaid is mandatory, and all states have a Medicaid program.

False

Supplemental Security Income (SSI) is a cash benefit program controlled by the Social Security Program.

False

The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program is a mandatory set of services and benefits for all individuals who are enrolled in Medicaid.

False

The time limit for filing Medicaid claims is the same from state to state: 2 months from each date of service.

False

Which of the following is NOT a designated group for determining eligibility for Medicaid?

Financially needy

What term describes an intentional misrepresentation or deception that could result in an unauthorized benefit to an individual?

Fraud

Which of the following is NOT a method that the health insurance professional can use to verify a patient's eligibility for Medicaid?

Having a witness vouch for an individual's eligibility

The payer of last resort is always:

Medicaid

What term describes the entity that specializes in administering government healthcare programs and with which individual states contract to process insurance claims?

Medicaid contractor

With the advent of the Medicare Modernization Act of 2003, full dual eligibles now receive their prescription drugs through the Medicare program, referred to as:

Medicare Part D

What does "reciprocity" mean as it relates to Medicaid?

One state's Medicaid program will pay for eligible services rendered to patients in a bordering state.

States may also receive federal funding if they elect to provide certain in addition to the mandatory services that each Medicaid program must provide under federal statute.

Optional services

Which of the following programs provides alternative care for non-institutionalized elderly who otherwise would need to be in a nursing home?

PACE

Which of the following is NOT included in other health insurance (OHI) for Medicaid recipients?

QMBs

What is another term for the explanation of benefits, or the document that a payer generates to explain how a payment was determined?

Remittance advice (RA)

Which organization administers Medicaid?

The Centers for Medicare and Medicaid Services (CMS)

What does color coding on Medicaid ID cards indicate?

The type of Medicaid program in which the recipient is enrolled.

A Medicaid secondary claim occurs when the beneficiary has two types of medical insurance coverage.

True

A procedure review rendered by the provider before the patient is admitted to the hospital and the procedure or service is performed is called preauthorization.

True

All Medicaid claims should be maintained for 6 years or longer if mandated by state statutes of limitation.

True

As a general rule, Medicaid only pays for services that are determined to be medically necessary.

True

Beginning in 2014, nearly everyone under age of 65 with income up to 133% of the FPL will be eligible for Medicaid.

True

Billing the recipient for any amount not paid by Medicaid is referred to as balance billing.

True

Individuals identified as Qualified Disabled and Working Individuals who lose their Medicare benefits because they returned to work are allowed to purchase Medicare hospital insurance.

True

Individuals who fall within the category of medically needy are those who would be eligible for Medicaid except that their income and/or resources are above the eligibility level. These individuals may qualify immediately or may spend down to qualify.

True

It is unacceptable to discard paper records in a trash bin because of security violations.

True

Medicaid claims are normally returned to the provider for correction and resubmission when certain errors/omissions are detected.

True

Medicaid is a program that is jointly funded by both states and federal governments.

True

Title XIX of the Social Security Act requires that for a state to receive federal matching funds for their Medicaid programs, certain basic services must be offered to the categorically needy population in any state program.

True

When one state allows Medicaid beneficiaries from other states to be treated in its medical facilities, this exchange of privileges is referred to as:

reciprocity