WHO FUNDED medicaid?
Medicaid claims should be submitted on
CMS-1500 forms
Another copay question, what is the rule behind copay? Are they allowed?
In 2002 and 2003, states across the nation faced steep budget shortfalls. A vast majority of them made cuts of some kind in their Medicaid programs by either instituting or boosting copayments for certain types of services or by eliminating some services. Copayment (copay) is a required specific dollar amount that must be collected at each office visit for medical services received by an individual. Under Medicaid, different copayment amounts may be set for each patient group as listed in Box 7.1 (which appears later in this chapter) and for certain medical procedures.
For medicaid patients, what should happen at every visit verify eligibility
see if the card is still active
Programs that are available for low income individuals?
Medicare Savings Programs (MSPs) help low-income individuals with out-of-pocket costs for Medicare, including Medicare Part A and Part B premiums, deductibles, copayments, and coinsurance. There are four types of MSPs • The Medicaid Qualified Medicare Beneficiary program was introduced in the Medicare Catastrophic Coverage Act of 1988 as an amendment to the Social Security Act.• Specified Low-Income Medicare Beneficiary program• Qualifying Individual program• Qualified Disabled and Working Individuals program All four types of MSP are run by state Medicaid programs. Each program addresses a different financial category, and the monthly income figures are adjusted each year. Eligibility for the programs may differ from state to state.
Theres another question around medicaid and managed care plans. Make sure understand managed care plan can i go to any hospital or do i have to go to a specific hospital?
Patients must use physicians, clinics, and hospitals that participate in their assigned plan
Time limit to appeal a claim
30 to 60 days
How far back can you retroactivate medicaid?
90 days
Time limits on medicaid claim submission
The time limit can vary from 2 months to 12 or 18 months from the date that the service was rendered. A bill can be rejected if it is submitted after the time limit unless the state recognizes some valid justification. Some states have separate procedures for billing over-one-year (OOY) claims. A percentage of the claim may be reduced according to the date of a delinquent submission. Prescription drugs and dental services are often billed to a different intermediary than are services performed by a physician or other health care provider, depending on the state guidelines.
Who the gatekeeper is as it pertains to medicaid
clinic or primary care physician [PCP]
What happens if service is disallowed by medicaid? Is it legal for physician to bill patient?
If this happens, in many states the health care organization is within his or her legal rights to bill the patient; consult state regulations before deciding to bill. However, it is wise to have the patient sign a waiver of liability agreement if the service to be provided may be a denied service from known past claim submission experience. Write or telephone the state agency to obtain up-to-date information and details on the Medicaid program in a particular state.
Spousal impoverishment protection law. What assets does that law protect
In 1988 Congress enacted provisions to prevent this which refers to leaving the spouse who is still living at home in the community with little or no income or resources. This is federal legislation that affects special financial provisions in Medicaid for the elderly, blind, or disabled. Formerly, if one partner (institutionalized spouse) needed to be in a nursing facility, a couples' income and assets would become so depleted to qualify that the other spouse (community spouse) did not have a sufficient amount to live on. This protection counts assets, such as cash, checking and savings accounts, life insurance policies, and certificates of deposits. It does not count the couples' home, car, household furnishings, burial assets (insurance, trust funds, or plots), clothing, or other personal items. This prevents the community spouse from being impoverished by his or her spouse's institutionalization.
OMNIBUS budget reconciliation act is
In 1990 the this of 1989 allowed for assistance to qualified Medicare beneficiaries (QMBs, pronounced "kwim-bees") who are aged and disabled, are receiving Medicare, and have annual incomes less than the FPL. Eligibility also depends on what other financial resources an individual might have. Under this Act, states must provide limited Medicaid coverage for QMBs. They must pay Medicare Part B premiums (and Part A premiums if applicable), along with necessary Medicare deductibles and coinsurance amounts.
Requirements for medicaid can an immigrant be approved for medicaid?
In general, Medicaid is available only to US citizens and certain "qualified immigrants." Passports and birth certificates must be submitted for proof of citizenship. Nonimmigrants and unauthorized aliens are not eligible for most federal benefits; however, states have the option to cover nonimmigrant and unauthorized aliens who are pregnant or who are children and can meet the definition of "lawfully residing" in the United States.
What does it mean when we talk about cost sharing or share of cost as it pertains to medicaid?
In the past, state Medicaid programs paid the Medicare deductibles and coinsurance for dual eligible cases at the full Medicare rate. However, the Balanced Budget Act of 1997 permits states to limit payment to the amount that the Medicaid program would otherwise pay for the service. Because of the health care reform legislation passed in 2010, many states have lowered their cost-sharing obligations for these cases to no more than the Medicaid payment amount for the same service. If the Medicare payment amount equals or exceeds the Medicaid payment rate, the state Medicaid program does not pay the Medicare deductible or coinsurance. The result is that the reimbursement becomes that of a Medicare-only patient even though it is crossed over to the Medicaid program.
Who medicaid is available to,
Low-income families • TANF-related groups • Non-TANF pregnant women and children • Infants born to Medicaid-eligible pregnant women • Recipients of adoption assistance or foster care assistance under Title IV-E of the Social Security Act • Aged, blind, and disabled • SSI-related groups • Qualified Medicare beneficiaries • Persons who receive institutional or other long-term care in nursing facilities and intermediate care facilities • Medicare-Medicaid beneficiaries
Who was responsible for the federal aspects of medicaid? What organization?
The Centers for Medicare and Medicaid
When medicaid pays a claim and sends a check, what form goes with the check?
remittance advice
The organization or physician must accept this if they accept medicaid patients
If the health care organization decides to take Medicaid patients, they must accept the Medicaid allowance as payment in full. The Medicaid allowance is the maximum dollar amount to be considered for payment for a service or procedure by the program.
Are there any services exempt from medicaid copay requirements?
Emergency care and pregnancy services are exempt by law from this. This may be a component of a state's general assistance program for low-income people
Federal emergency relief administration, purpose, what did they do?
Federal participation in providing medical care to needy persons began between 1933 and 1935 when this made funds available to pay the medical expenses of the needy unemployed.
Medicaid was legally established by who or what?
After the various attempts during the previous 30 years to provide medical care to the needy, in 1965 Title XIX of the Social Security Act became federal law and Medicaid legally came into being
Medicaid service for prevention early detection and treatment for welfare children is known as what acronym
Another benefit of the Medicaid program is the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service. This is a program of this children who are under the age of 21 and enrolled in Medicaid (Table 7.2). In California (Medi-Cal) it is known as the Child Health and Disability Prevention (CHDP) program and in Ohio as Healthchek. Because many states are changing the name of EPSDT and the services offered under the program, check with the state Medicaid vendor.
As it pertains to medicaid, know what a fee for service program service, managed care program,
As early as 1967, some states began bringing mc to their Medicaid programs. Over the past decade, many states adopted pilot projects to determine whether a mc system would work and what benefits might be received. Mainly this was done to control escalating health care costs by curbing unnecessary emergency department visits and emphasizing preventive care. When Arizona started its Medicaid program, it began with prepaid care rather than adhering to the way most states have structured their programs. By then, most states had been struggling with Medicaid for nearly 20 years. In these systems the Medicaid recipient enrolls in either an existing or a specifically formed plan similar to a health maintenance organization (HMO). The patient either may be assigned or may choose a gatekeeper (clinic or primary care physician [PCP]) who must approve all specialty care and inpatient or outpatient hospital treatment. Patients must use physicians, clinics, and hospitals that participate in their assigned plan. Some doctors prefer to operate on a contract-to-contract, per-patient basis rather than be a participating provider. Patients can be cared for side by side with private-paying patients. Some states have adopted capitation (a flat fee per patient) rather than ffs reimbursement. There may be a small copayment for services. It has been found that there is better access to primary health care and savings of monies in delivering the care if the Medicaid programs are well managed
DERFA and CHAP? Deficit Reduction Act (DEFRA) of 1984 and the Child Health Assurance Program (CHAP)
Changes in Medicaid eligibility allowing more people into the program were made by many states after the passage of the former and the latter by the federal government. On July 1, 2006, as part of the former, a federal law became effective requiring new applicants and current beneficiaries renewing their benefits (except seniors and people with disabilities) to submit birth certificates, passports, or other documents to establish their legal right to benefits as US citizens. If no documentation of citizenship can be found, sworn affidavits from the beneficiary and at least one or two other individuals can be used.
What CHIP is? Acronym and what did it provide?
Children's Health Insurance Program is a partnership between the federal and state governments that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, this also covers care for pregnant women. Each state and certain other jurisdictions, including territories and the District of Columbia (56 programs total), operate a this. This insures children from families whose income is less than 200% of the FPL or whose family has an income 50% higher than the state's Medicaid eligibility threshold. However, some states have expanded this eligibility beyond the 200% FPL limit, and others are covering entire families and not just children. States have three options in designing their program. The state can do one of the following:• Use this funds to expand Medicaid eligibility to children who previously did not qualify for the program.• Design a children's health insurance program that is entirely separate from Medicaid. Combine both the Medicaid and the separate program options
What office oversees state law enforcement for compliance and performance with federal requirements?
Each state has a Medicaid Fraud Control Unit (MFCU), which is a federally funded state law enforcement entity usually located in the state attorney general's office. The MFCU employ teams of investigators, attorneys, and auditors who investigate and prosecute cases of fraud and other violations, including complaints of mistreatment in long-term care facilities. The Office of Inspector General (OIG) oversees and assess the MFCU for performance and compliance with federal requirements.
PPACA acronym
Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act (HCERA), was passed. These Acts affect the Medicaid program by expanding access for childless adults and nonelderly and nonpregnant individuals, and include preventive services and long-term care benefits. Additional funds were allocated for maternal and child health services. created the Community First Choice Option, a plan that allowed state Medicaid plans to provide medical assistance for home- and community-based attendant services and support to eligible individuals. The Community First Choice Option became available in 2011. This created the opportunity for states to expand Medicaid to cover nearly all low-income Americans younger than 65. States were given the option to extend Medicaid eligibility to adults with incomes at or less than 133% of the federal poverty level (FPL). The FPL is a measure of income issued every year by the Department of Health and Human Services (HHS). As of January 1, 2017, 32 states have chosen to expand their programs; 19 states have no
Medicaid there are two types of copayment requirements that may apply to the state medicaid program, what are they?
Some states require a small fixed copayment paid to the provider at the time services are rendered. This policy was instituted to help pay some of the administrative costs of providers participating in the Medicaid program. Another requirement is the share of cost or spend down copayment. Some Medicaid recipients must meet this copayment requirement each month before Medicaid benefits can be claimed. For example, if an individual's income is too high to qualify, some states allow deduction of certain medical expenses from his or her income so that the income may fall within Medicaid guidelines. These spend down programs are available in some states for the aged, the blind, or those who have a disability. Spend down eligibility is a monthly process and patients must submit proof of medical expenses that meet the spend down amount. Expenses covered by other insurance are not eligible to be used toward the spend down amount. For example, if the income is $150 more than the limit, the excess income is equal to the spend down amount and the patient must submit $150 of acceptable medical bills or pay in the spend down amount to receive Medicaid coverage for the remainder of the month. Because the amount may change from month to month, be sure to verify the copayment each time it is collected. Obtain this copayment amount when the patient comes in for medical care and report on the claim form that it has been collected.
How SSI impacts or correlates with medicaid
The Temporary Assistance for Needy Families (TANF) program is a federal assistance program that began on July 1, 1997. The program provides limited cash assistance to extremely low-income parents and their children. TANF assists families with children when the parents or other responsible relatives cannot provide for the family's basic needs. The federal government provides grants to states to run the TANF program. States may have different names for this program, and it can be called welfare, public assistance, temporary assistance, general assistance, or cash assistance. Other individuals who may be considered categorically needy are most cash recipients of the Supplemental Security Income (SSI) program; other SSI-related groups; QMBs; and patients in institutional, long-term care, and intermediate care facilities (see Box 7.1). A recipient is an individual certified by the local welfare department to receive benefits of Medicaid under one of the specific aid categories.
How often are medicaid id cards issued?
Under certain classifications of eligibility, identification cards are issued in some states on the first and fifteenth of each month, every 2 months, every 3 months, or every 6 months. Sometimes an unborn child can be issued an identification card that is used for services promoting the life and health of the fetus.
According to the book, there's a specific way the book talks about verification insurance eligibility.
When professional services are rendered, eligibility for that month must be verified. Verification is done if several ways, depending on how the state has developed their process. For example, the Nashville-based company Medifax provides internet Medicaid eligibility verification to California, North Carolina, New Jersey, and Georgia. Medifax provides real-time, online access to patient eligibility and benefit information for health care providers. Some states provide their own electronic system for Medicaid verification via touchtone telephone, modem, or specialized Medicaid terminal equipment, such as a point-of-service (POS) machine (Fig. 7.3). New York State utilizes a POS verification device that uses basic analog telephone outlets to connect with their Medicaid Verification System (MEVS).
What did Social security act 1935 do or provide?
created the public assistance programs. Although no special provision was made for medical insurance, the federal government paid a share of the monthly income assistance payments, which the individual could use to meet the costs of medical care. After the various attempts during the previous 30 years to provide medical care to the needy, in 1965 Title XIX of the Social Security Act became federal law and Medicaid legally came into being. Under the program, the federal government provided matching funds to states to enable them to provide medical assistance to individuals whose incomes and resources were insufficient to meet the costs of necessary medical services.
As it pertains to medicaid and healthcare organizations, can providers choose to refuse medicaid patients, and if they can, what is this criteria based off
health care organization or provider must enroll for participation in the Medicaid program. The enrolling service provider must sign a written agreement with the fiscal agent as part of the application process. In the Medicaid program, a fiscal agent is an organization under contract to the state to process claims for a state Medicaid program. Health care organizations and service providers have their own office procedures for handling Medicaid patients. The organization or provider may accept or refuse to treat Medicaid patients but must make the decision based on the entire Medicaid program, not an individual patient's personality, medical situation, or other discriminating factor. The patient must receive quality care and be treated the same as the paying patient. If the health care organization decides to take Medicaid patients, they must accept the Medicaid allowance as payment in full. The Medicaid allowance is the maximum dollar amount to be considered for payment for a service or procedure by the program.
What is the name for california's medicaid program
medi-cal
Optional eligibility groups
• Low-income persons who are losing employer health insurance coverage (Medicaid purchase if person has Consolidated Omnibus Budget Reconciliation Act coverage) • Infants up to age 1 and pregnant women not covered under the mandatory rules whose family income is not more than 185% of the federal poverty level (note that the percentage may be modified by each state) • Children younger than age 21 who meet TANF income and resource requirements but who are otherwise not eligible for TANF • Persons who would be eligible if institutionalized but receive care under home- and community-based service waivers • Persons infected with tuberculosis who would be financially eligible for Medicaid at the SSI income level if they were within a Medicaid-covered category (limited coverage) • Low-income children with the State Children's Health Insurance Program • Low-income, uninsured women who are diagnosed through the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program and who need treatment for breast or cervical cancer
Medicaid is considered what? When you have multiple insurances?
Payer of last resort. It is possible that a person can be eligible for Medicaid and also have group health insurance coverage through an employer. When Medicaid and a third-party payer cover the patient, Medicaid is always considered the payer of last resort. The third-party payer (other insurance) is billed first. After a remittance advice (RA) or check voucher is received from the primary carrier, Medicaid (the secondary carrier) is billed. A copy of the RA or check voucher is enclosed.
prior approval
is the evaluation of a provider's request for a specific good or service to determine the medical necessity and appropriateness of the care requested for the patient. In some states this may be referred to as prior authorization. Some of these goods and services are the following: • Durable medical equipment • Hearing aids • Hemodialysis • Home health care • Inpatient hospital care • Long-term care facility services • Medical supplies • Medications • Prosthetic or orthotic appliances • Some vision care • Surgical procedures • Transportation Usually prior authorization forms are completed to obtain permission for a specific service or hospitalization (Fig. 7.4) and mailed or faxed to the Department of Health or a certain office in a region for approval. In some cases, time does not allow for a written request to be sent for prior approval, so an immediate authorization can be obtained via a telephone call to the proper department in any locale. Note the date and time that the authorization was given, the name of the person who gave authorization, and any verbal number given by the field office. Usually a treatment authorization form indicating that the service was already authorized must be sent in as follow-up to the telephone call.
