chapter 8 medical billing

Medicaid is a major social welfare program administered by the

CMS

The Medicaid program is administered by the:

CMS.

What program was enacted by Congress in 1996 to make sure that the public has access to emergency services regardless of ability to pay?

Emergency Medical Treatment and Labor Act (EMTALA)

The ACA's new, simplified method for calculating eligibility for Medicaid and CHIP is based on a person's adjusted gross income plus any tax-exempt Social Security, interest, or other income called

MAGI

A commercial insurer contracted by the Department of Health and Human Services (HHS) for the purpose of processing and administering Medicaid claims is a:

Medicaid contractor.

The process of increasing the number of people enrolled in Medicaid by making it easier for people to qualify for Medicaid is referred to as the

Medicaid expansion.

A combination federal/state medical assistance program that provides comprehensive and quality medical care for certain categories of low-income and qualifying elderly people is:

Medicaid.

The acronym for the program that provides comprehensive alternative care for noninstitutionalized elderly who otherwise would be in a nursing home is:

PACE.

The acronym for the Medicaid program that was formerly referred to as AFDC is:

TANF.

When an individual meets the eligibility requirements for both Medicare and Medicaid he or she qualifies as being

a dual eligible.

In order to be eligible for SSI, the individual must meet all of the following criteria, except:

be single.

Medicaid is a medical assistance program funded by ________________, designed to provide comprehensive and quality medical care for people who are unable to pay some or all of their own medical expenses.

both the US and state governments

Individuals who receive medical assistance because their income falls within the poverty or FPL guidelines or as a result of SSI eligibility are considered:

categorically needy

The process by which the healthcare provider bills and collects from liable third parties before sending the claim to Medicaid is referred to as

cost avoidance

Each state sets its own Medicaid eligibility rules under broad federal guidelines, but in general, state programs must cover all of the following groups except

disabled veterans of foreign wars.

The ACA provides Americans with opportunities for better healthcare by putting in place comprehensive health insurance reforms that

expand coverage; guarantee more choices in healthcare coverage; hold insurance companies accountable

An intentional misrepresentation that could result in an unauthorized benefit to an individual, usually in the form of a false statement requesting payment, is a definition of

fraud

In order for federal matching funds in a state's Medicaid program to be received, Title XIX of the Social Security Act requires that states offer certain basic services called:

mandated services.

When a procedure is consistent with the diagnosis and in accordance with the standards of good medical practice, performed at the proper level, and provided in the most appropriate setting, it is said to be

medically necessary

State participation in Medicaid, other than those benefits mandated by the federal government, is

optional

Since Medicaid does not pay on a claim until all available third-party resources have met their legal obligations to pay, it is said to be the

payer of last resort.

Medically needy individuals can reduce their assets to the Medicaid eligibility level by deducting medical expenses; this is called a/an:

spend down.

In 1972, federal law established a program that provides federally funded cash assistance to qualifying elderly and disabled poor named the

supplemental security income (SSI) program.

To qualify for supplemental security income (SSI), individuals must meet certain financial guidelines set by:

the federal poverty level (FPL).

Under fee-for-service, Medicaid payment rates are based on all of the following except

what the patient can afford