When did federal participation in providing needy persons with medical care begin?
between 1933 and 1935 when the Emergency Relief Administration made funds available to pay the medical expenses of the needy unemployed.
In 1950 Congress passed a law mandating what?
that all states set up a health care program of assistance (meaning that the states had to meet minimum requirments).
Congress authorized vendor payments for what?
medical care - payments from the wlefare agency directly to physicians, health care institutions, and other providers of medical services.
A new category of assistance receipient was established for who?
the medically needy aged population
Who is the medically needy aged population?
inidividuals whose incomes are too high to qualify them for cash assistance payments, but they need help inmeeting the costs of medical care.
Who is responsible for the federal aspects of Medicaid?
CMS (center for Medicaid and Medicare Services); the STATE
What act allowed for qualified Medicare beneficiaries (QMBs)?
the 1991 Omnibus Budget Reconciliation Act
Who are qualified Medicare beneficiaries?
individuals who are aged and disabled and are receiving Medicare and have annual incomes below the federal poverty level.
Medicaid is available for who?
certain needy and low-income people such as the elderly (65 years or older), blind, disabled, and members of families with dependent children (deprived of the support of at least one parent) and financially eligible on the basis of income and resources
What specific conditions qualify children for benefits under the MCHP?
all state laws include children who have some kind of handicap that requires orthopedic treatment or plastic surgery; a few states add other conditions
How long can a patient participate in the Medicaid program?
a patient could be on Medicaid for one month or several months at a time; each case is different.
What must a physician do if he agrees to take Medicaid patients?
accept the Medicaid allowance as payment in full.
What is the Medicaid allowance?
the maximum dollar amount to be considered for payment for a service or procedure by Medicaid.
What should be done with the patient's identification card each time they visit the office?
the expiration date should be checked,you should note if the patient has other insurance, copayment requirments, or restrictions such as being eligible for only certain types of medical services
Point-of-service Machines: When professional services are rendered what must be done?
eligibility for that month must be verified.
What is the EPSDT (Early and Periodic Screening, Diagnosis, and Treatment)?
a program of prevention, early detection, and treatment of welfare children.
Why was Medicaid Managed Care established?
to control escalating health care costs by curbing unnecessary emergency department visits and emplasizing preventative care.
When may Prior approval be needed?
it is necessary for various services except a bona fide emergency
What do you do when filing a claim for a Medicaid managed care patient?
send the bill or claim form to the managed care organization (MCO) and nto Medicaid
When Medicare and a third-party payer cover a patient, who is billed first?
the third-party payer (other insurance) is billed first. Medicaid is ALWAYS considered a last resort.
What is the time limit to appeal a claim?
it varies from state to state, but it is usually 30 to 60 days from the date listed on the Remittance Advice
Who can be enrollees of CHAMPUS?
dependents of personnel who are actively serving in the armed services and military retirees and their dependents.
Define service retiree or military retiree
peopel who are retired from a career in the armed forces and remain in TRICARE until the age of 65, when they obtain Medicare.
What is NAS?
a certification from a military hospital stating that they cannot provide the needed care.
What is a catchment area?
a specific geographic region defined by ZIP code based on area of 40 miles surrounding each MTF (Military Treatment Facility)
What is cooperative care?
services or supplies that may be cost shared by TRICARE Standard under certain conditions.
Who is an authorized provider
a physician or other individual authorized provider of care or a hospital or supplier approved by TRICARE to provide medical care and supplies
List 4 examples of an authorized provider
1) Doctor of Medicine MD (2) Doctor of Osteopathy DO or MD (3) Doctor of optometry DO (4) Psychologist
What does an HCF do?
assist with the referral or preauthorization request, when services are not available. Helps the patient work with their PCP to locate a specialist or get preauthorization for care.
How do you enroll in TRICARE Prime?
by completing an application and agreeing to enroll for a minimum of 12 months as a member.
What is a PCM in TRICARE?
a primary care manager that the beneficiary can choose or be assigned for each family member.
What does the PCM do?
manages all aspects of the patient's health care (except emergencies) including referrals to specialists.
When is the wife of a service disabled person due to a work related injury eligible for CHAMPVA?
when she is not eligible for TRICARE or Medicare Part A as a result of reaching age 65.
What did the Privacy Act of 1974 do?
establish an individual's right to review his/her medical record and to contest inaccuracies in medical records..
the Privacy Act of 1974 is maintain by who?
by a federal medical facility such as a VA medical center or US Public Health Service facility
How do providers submit claims with TRICARE Extra or TRICARE Prime?
electronically with a 837P claim to TRICARE subcontractors for services given.
What is the time limit to file claims with TRICARE Extra/Prime?
a 1 year deadline applies to each item on the claim
By law, when is TRICARE/CHAMPVA the secondary payer?
when a beneficiary is enrolled in other health insurance (OHI) or a civilian health plan.