issues and trends in hbi ch 10

CHAPTER

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10Medicaid

Learning Outcomes

When you finish this chapter, you will be able to:10.1 Discuss the purpose of the Medicaid program.

10.2 Discuss general eligibility requirements for Medicaid.

10.3 Assess the income and asset guidelines used by most states to determine eligibility.

10.4 Evaluate the importance of verifying a patient’s Medicaid enrollment.

10.5 Explain the services that Medicaid usually does not cover.

10-2

Learning Outcomes (continued)

When you finish this chapter, you will be able to:10.6 Describe the types of plans that states offer

Medicaid recipients.

10.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage.

10.8 Prepare accurate Medicaid claims.

10-3

Key Terms

• categorically needy• Children’s Health

Insurance Program (CHIP)

• crossover claim• dual-eligible• Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT)

• Federal Medicaid Assistance Percentage (FMAP)

10-4

• Medicaid Integrity Program (MIP)

• MediCal

• medically needy

• Medi-Medi beneficiary

• payer of last resort

• restricted status

• spenddown

• Temporary Assistance for Needy Families (TANF)

• Welfare Reform Act

10.1 The Medicaid Program 10-5

• Medicaid was established to pay for the healthcare needs of individuals and families with low incomes and few resources

• Federal Medicaid Assistance Percentage (FMAP)—basis for federal government Medicaid allocations to states

10.2 Eligibility 10-6

• Federal guidelines mandate coverage for individuals referred to as categorically needy—people who receive assistance from government programs

• Temporary Assistance for Needy Families (TANF)—program that provides cash assistance for low-income families

10.2 Eligibility (continued) 10-7

• Medicaid coverage is available to:– People receiving TANF assistance– People eligible for TANF but not receiving assistance– People receiving foster care or adoption assistance

under the Social Security Act– Children under six years of age from low-income

families– Some people who lose cash assistance when their

work income or Social Security benefits exceed allowable limits

– Infants born to Medicaid-eligible pregnant women

10.2 Eligibility (continued) 10-8

• Medicaid coverage is available to (continued):– People age sixty-five and over or legally blind or

totally disabled people who receive Supplemental Security Income (SSI)

– Certain low-income Medicare recipients

• The federal government requires the states to provide individuals in certain low-income or low-resource categories with Medicaid coverage

10.2 Eligibility (continued) 10-9

• Children’s Health Insurance Program (CHIP)—offers health insurance coverage for uninsured children

• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)—Medicaid’s prevention, early detection, and treatment program for eligible children under twenty-one

• Welfare Reform Act—law that established TANF and tightened Medicaid eligibility requirements

10.3 State Programs 10-10

• States establish their own eligibility standards• When determining eligibility, states examine a

person’s:– Income– Current assets (some assets are not counted)– Assets that have recently been transferred into

another person’s name

10.3 State Programs (continued) 10-11

• Medically needy—classification for people with high medical expenses and low financial resources

• MediCal—California’s Medicaid program• Spenddown—state-based Medicaid program

requiring beneficiaries to pay part of their monthly medical expenses

10.4 Medicaid Enrollment Verification 10-12

• Patients’ eligibility should be checked each time they make an appointment and before they see a physician– Patient’s Medicaid identification cards should be

checked; in addition, a second form of identification is often checked

• Many states are developing the electronic verification of eligibility, in addition to telephone verification systems

10.4 Medicaid Enrollment Verification (continued)

10-13

• Restricted status—category of Medicaid beneficiary

• Medicaid Integrity Program (MIP)—created to prevent and reduce fraud, waste, and abuse in Medicaid

10.5 Covered and Excluded Services 10-14

• States must cover certain services to receive federal matching funds– Some states also provide coverage for prescription

drugs, dental or vision care, and other miscellaneous services

• Medicaid usually does not pay for:– Services that are not medically necessary– Procedures that are experimental or investigational– Cosmetic procedures

10.6 Plans and Payments 10-15

• States offer a variety of plans, including fee-for-service and managed care plans– The trend is to shift recipients from fee-for-service

plans to managed care plans

• A physician who wishes to provide services to Medicaid recipients must sign a contract with the Department of Health and Human Services (HHS)

10.7 Third-Party Liability 10-16

• Before filing a claim with Medicaid, it is important to determine whether the patient has other insurance coverage– Other plan is billed first, then once the remittance

advice from the primary carrier has been received, Medicaid may be billed

• Payer of last resort—regulation that Medicaid pays last on a claim

10.7 Third-Party Liability (continued) 10-17

• Medi-Medi beneficiary—person eligible for both Medicare and Medicaid– Dual-eligible—Medicare-Medicaid beneficiary

• Crossover claim—claim for a Medicare or Medicaid beneficiary

10.8 Claim Filing and CompletionGuidelines

10-18

• Medical insurance specialists follow the general instructions for correct claims and also enter particular Medicaid data elements

• They need to know:– Where to file claims– Proper Medicaid coding methods– Unacceptable billing practices– Actions to take after filing a claim

Summary

Summary

Summary