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