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adjusted claim

payment correction resulting in additional payments to the provider

dual eligibles

individuals entitled to Medicare and eligible for some type of Medicaid benefit

federal poverty level (FPL)

income guidelines established annually by the federal government

Medicaid

cost-sharing program between the federal and state governments to provide healthcare services to low-income Americans; originally administered by the Social and Rehabilitation Service (SRS)

Medicaid remittance advice

sent to the provider; serves as an explanation of benefits from Medicaid and contains the current status of all claims (including adjusted and voided claims)

Medical assistance program

program for individuals with incomes below the federal poverty level

recipient eligibility verification system (REVS)

aka Medicaid EVS; allows providers to electronically access the state's eligibility file through point-of-sale device, computer software, and automated voice response

Temporary Assistance for Needy Families (TANF)

makes cash assistance available on a time-limited basis for children deprived of support because of a parent's death, incapacity, absence, or unemployment

voided claim

claim medicaid should not have originally paid, resulting in a deduction from the lump-sum payment made to the provider

Medicaid is jointly funded by federal and state governments, and each state:

administers its own Medicaid program

State legislatures may change Medicaid eligibility requirements:

during the year, sometimes more than once

What requirements are used to determine Medicaid eligibility for mandatory categorically needy eligibility groups?

Anyone who meets (TANF) eligibility requirements, (SSI) recipients, Caretakers who take care of a child under age 18, pregnant women and children under age 6 whose family income is at or below 133% of (FPL)

States that opt to include a medically needy eligibility group in their Medicaid program are required to include certain children who are under the age of _____ and who are full-time students

21

What allows states to create or expand existing insurance programs to include a greater number of children who are uninsured?

State Children's Health Insurance Program (SCHIP)

list some services that are considered a mandatory Medicaid service that states must offer to receive federal matching funds:

Family planning services and supplies, physician's services, home health aides, pregnancy related services + 60 day postpartum, inpatient/outpatient, labs/x-rays, etc.

When a patient has Medicaid coverage in addition to other, third-party payer coverage, Medicaid is always considered the:

payer of last resort

What is considered a voided claim?

A claim that Medicaid should not have originally paid and results in a deduction from the lump-sum payment made tot he provider

Medicaid-covered services are paid only when the service is determined by the provider to be medically necessary, which means the services are:

consistent with the patient's symptoms, diagnosis, condition, or injury

PARS to medicaid:

Always accept Medicaid payments as payment in full, and balance billing is illegal

List some things to remember about this chapter:

1. Categorically needy group gets 'the whole pie'. 2. Medicaid is both an HMO and a pre-paid service. 3. Low income is only one requirement of many to determine eligibility. 4. Medicaid is not an insurance, it is a medical assistance program.

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