Medical insurance billing chapter 10

Eligible for medicaid

-legally blind & receive supplemental security income -pregnant women whose family income is below 133% of the poverty level - infants born to medicaid eligible women - people with low incomes and few resources who receive financial assistance under TANF - people who receive foster care or adoption assistance -children under six who meet TANF requirements -certain low income medicare recipients -people 65 & over, legally blind, or totally disabled who receive SSI

Not eligible for medicaid

-people who are eligible for TANF & receive financial assistance -people with moderate incomes and many resources who receive financial assistance under TANF -children between the ages of 7-18 yrs old who meet TANF requirements

he Affordable Care Act is expected to add how many million people into the Medicaid program?

16 million

hildren under __________years old who meet TANF requirements must be offered state Medicaid benefits.

6

CHIP is the abbreviation for

Children's Health Insurance Program

Covers children up to age nineteen provides coverage for many preventative services, physicians services, inpatient and outpatient services

Children's health insurance program (CHIP)

a physician who wishes to provide services to medicaid recipients must sign a contract with the

Dept of human services

Most states are moving to electronic verification of Medicaid eligibility under the:

EMEVS

Covers health services other than periodic health screenings Medical, vision, hearing, and dental health screenings(known as well child check ups) are performed at regular intervals

Early & periodic screening, diagnosis, and treatment

EPSDT is the abbreviation for

Early and Periodic Screening, Diagnosis, and Treatment

Medicaid claims are usually submitted using the _________claim.

HIPAA837P

Provide necessary supports to allow the elderly and people with disabilities to fully participate in community life

New freedom initiave

Applies to situations in which one member of a couple is in a nursing facility or medical institution and is expected to remain there for at least thirty days

Spousal impoverishment protection

What does the abbreviation SSI stand for?

Supplemental Security Income

TANF is the abbreviation for

Temporary Assistance for Needy Families

Gives states the option of allowing individuals with disabilities to purchase medicaid coverage that is necessary to enable them to maintain employment

The ticket to work and work incentives improvement act

affected eligibility rules for several other groups, including disabled children and immigrants

Welfare Reform Act

Assets that have been transferred into _____ are closely examined. The asset may be included in the applicants asset depending on when the asset was transferred, to whom, the amount paid in return, and the state in which the applicant resides

another persons name

Applicants who enter a long term care facility have their homes counted as an _____ unless they are in for a short term stay and are expected to return home shortly or if relatives will continue to live in the home

asset

Individuals who are eligible for both Medicaid and Medicare benefits are called

both dual-eligibles and Medi-Medi beneficiaries

ndividuals receiving financial assistance under TANF due to low incomes and few resources must be covered

by state Medicaid programs

Providers in _____ who are paid flat monthly fees must still file claims with the medicaid payer, since the payer uses the claim data to access utilization

capitated managed care plans

assets are taken into account when determining eligibility, assets include The applicants _____ is not counted in arriving at the total asset calculation. Assets may be owned solely by the applicant or jointly by the applicant and another party.

cash, bank accounts, certificates of deposit, stocks and bonds, cash surrender value of life insurance policy, and property other than homes residence

Under the Medicaid program which of the following is true

categorically needy and medically needy do not have the same meaning

the following is NOT offered under the Medicaid program

comprehensive health insurance coverage, cosmetic procedures, and free prescriptions are offered to pregnant women whose family income is below 133 percent of the poverty level.

Claims billed to Medicare which are automatically sent to Medicaid are called

crossover claims

states may require recipients to make small payments in the form of _____, _____, or _____

deductibles, coinsurance, copayments

The medical insurance specialist should check patients' Medicaid eligibility:

each time an appointment is made

Federal law mandates exempting _____ and _____ from _____

emergency services, family planning services, copayments

People who receive income form _____ may qualify for medicaid depending on their income, since a portion of their _____ is not counted toward the medical income limit

employment, earned income

many states have shifted the medicaid population from _____ programs to _____

fee-for-service programs, managed care plans

The Temporary Assistance for Needy Families provides which of the following?

financial assistance to beneficiaries

Categorically needy people in the Medicaid program usually have

low incomes

client enrollment in a managed care plan is either _____ or _____ depending on state regulations

mandatory, voluntary

A person eligible for Medicaid in a given state is

not necessarily eligible in all other states

In a spend down program, beneficiaries are required to:

pay part of their monthly expenses

Medicaid is known as the _____________________, since it is always billed after another plan has been billed, if other coverage exists.

payer of last resort

States must cover all of the following to receive federal funding, except:

prescription drugs

individuals enrolled in managed care plans must obtain all services and referrals through their

primary care provider

Information provided on the application is checked and verified using other sources of information, including

social security administration, the internal revenue service, the state motor vehicle agency, and the state department of Labor among others

If the patient needs to see a _____ the PCP must provide a _____; otherwise, the managed care plan will not pay for the service

specialist, referral

A crossover claim is automatically:

transmitted by the primary payer to the secondary payer.

only a portion of _____ from social security benefits, SSI, veterans benefits, and pensions is counted toward _____

unearned income, income limits