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ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 ANSWERS TO THINKING IT THROUGH Thinking It Through 10.1 page 359 1. Answers will vary depending upon the student's state, but they should come up with a list of information about Medicaid eligibility requirements, benefits, and limitations. An example of this type of information for the state of Maryland can be found at: http://www.dhmh.state.md.us/mma/Eligibility/medcareprog/html/MCP-program.html. Thinking It Through 10.2 page 362 1. Students should identify the importance of health care services for people with low-incomes who are unable to afford coverage, particularly for children who would not otherwise have an opportunity for coverage. They may also point out that providing children with quality health care will generally decrease their lifelong health care expenses as a result. Thinking It Through 10.3 page 365 1. A. Medicaid eligibility rules and coverage vary because Medicaid is an assistance program for individuals and families with low incomes and few resources. Economic conditions and the cost of living vary greatly from state to state. An income that is considered low in one state may be regarded as moderate in another state, where the salaries and cost of living are lower. Medicare is open to all people over age sixty-five (and people with certain disabilities); eligibility is not based on income and assets. B. Advantages to the current state-oriented system are that it allows states the latitude to develop programs to meet the unique needs of their residents and that eligibility rules take into account variations in income and the cost of living in a particular state. Disadvantages include complicated claim filing and processing, since coverage varies by state. This is especially a problem in an area where a physician may see patients from several states (such as the New York City or Washington, D.C., area). Another disadvantage is that individuals who did not meet eligibility requirements in one state and who move to another state may not know whether they now qualify for Medicaid. Thinking It Through 10.4 page 369 1. Student answers will vary, but they may point out that medical insurance specialists can recommend that their medical practice expand their office policies to help prevent fraud, and could incorporate checkpoints with multiple office personnel to limit opportunities for fraud. Thinking It Through 10.5 page 370 1. Medicaid distinguishes between categorically needy and medically needy individuals. Categorically needy individuals receive assistance due to their low incomes, while medically needy individuals require

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Page 1: ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 Insurance...ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 ANSWERS TO THINKING IT THROUGH Thinking It Through 10.1 page 359 1. Answers

ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10

ANSWERS TO THINKING IT THROUGH

Thinking It Through 10.1 page 359

1. Answers will vary depending upon the student's state, but they should come up with a list of information about Medicaid eligibility requirements, benefits, and limitations. An example of this type of information for the state of Maryland can be found at: http://www.dhmh.state.md.us/mma/Eligibility/medcareprog/html/MCP-program.html.

Thinking It Through 10.2 page 362

1. Students should identify the importance of health care services for people with low-incomes who are unable to afford coverage, particularly for children who would not otherwise have an opportunity for coverage. They may also point out that providing children with quality health care will generally decrease their lifelong health care expenses as a result.

Thinking It Through 10.3 page 365

1. A. Medicaid eligibility rules and coverage vary because Medicaid is an assistance program for individuals and families with low incomes and few resources. Economic conditions and the cost of living vary greatly from state to state. An income that is considered low in one state may be regarded as moderate in another state, where the salaries and cost of living are lower.

Medicare is open to all people over age sixty-five (and people with certain disabilities); eligibility is not based on income and assets.

B. Advantages to the current state-oriented system are that it allows states the latitude to develop programs to meet the unique needs of their residents and that eligibility rules take into account variations in income and the cost of living in a particular state. Disadvantages include complicated claim filing and processing, since coverage varies by state. This is especially a problem in an area where a physician may see patients from several states (such as the New York City or Washington, D.C., area). Another disadvantage is that individuals who did not meet eligibility requirements in one state and who move to another state may not know whether they now qualify for Medicaid.

Thinking It Through 10.4 page 369

1. Student answers will vary, but they may point out that medical insurance specialists can recommend that their medical practice expand their office policies to help prevent fraud, and could incorporate checkpoints with multiple office personnel to limit opportunities for fraud.

Thinking It Through 10.5 page 370

1. Medicaid distinguishes between categorically needy and medically needy individuals. Categorically needy individuals receive assistance due to their low incomes, while medically needy individuals require

Page 2: ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 Insurance...ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 ANSWERS TO THINKING IT THROUGH Thinking It Through 10.1 page 359 1. Answers

assistance largely due to their high medical expenses in conjunction with low financial resources.

Thinking It Through 10.6 page 371

1. For fee-for-service claims, the provider submits the claim to Medicaid and is paid directly by Medicaid. However, managed care claims are sent to the managed care organization instead of the state Medicaid department.

Thinking It Through 10.7 page 372

1. Medicare-Medicaid crossover claims are sent first to Medicare, which makes payment to the provider and then sends the claim on to Medicaid.

ANSWERS TO REVIEW QUESTIONS

Matching page 376

1. J

2. H

3. D

4. F

5. B

6. E

7. G

8. A

9. C

10. I

Multiple Choice page 377

1. D

2. A

3. B

4. D

5. D

6. A

7. D

8. D

9. A

10. B

Completion page 377

1. Depending on the state, verify eligibility electronically, via the telephone, or by examining the identification card.

2. Ask for other identification to confirm identity.

ANSWERS TO APPLYING YOUR KNOWLEDGE pages 378-380

Cases 10.1 and 10.2 require claim completion. Students may complete paper CMS-1500 forms by hand

Page 3: ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 Insurance...ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 ANSWERS TO THINKING IT THROUGH Thinking It Through 10.1 page 359 1. Answers

or by using the electronic CMS-1500 form. They may also use the simulated Medisoft Connect Plus exercises to create and print the claims. The claim case answer keys provided in this Instructor’s Manual are based on completion of paper CMS-1500 claim forms using the electronic form.

Case 10.1

Page 4: ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 Insurance...ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 ANSWERS TO THINKING IT THROUGH Thinking It Through 10.1 page 359 1. Answers

Case 10.2

Page 5: ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 Insurance...ANSWERS TO EXERCISES IN TEXTBOOK - Chapter 10 ANSWERS TO THINKING IT THROUGH Thinking It Through 10.1 page 359 1. Answers