medicaid ch 15 part 1

37 terms by dinabobina27 

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In 1985 Congress passed Title 19 of the Social Sequrity Act, establishing a federal mandated

state administered MEDICAL ASSITING PROGRAM for individuals woth incomes below the federal poverty level

Medicaid provides medical and health-related services to certain individuals and families with

low incomes and limited resources (the "medically indigent")

Within broad federal guidelines each state

Establishes its own eligibilty standards, Determines the type, amount, duration, and scope of services, Sets rates of payment for services, Adminsters its own program

Each state adminsters its own MEdicaidprogram and

CMS monitors the programs and establishes requirements for the delivry, funding, and quality of services as well as eligibilty criteria

TANF also known as

Temporary Assistance for Needy Families

Families who meet states Temporary Assistance for Needy Families (TANF)
(Categorically Needy Groups)

eligibilty requirements in effective on July 16, 1996

Pregnant women and children under age 6 whose family income is
(Categorically Needy Groups)

at or below 133% of the federal poverty level

Individuals and couples living in medical institutions who have a
(Categorically Needy Groups)

monthly income up to 300% of the SSI income

MEdicaly needy is NOT

for patients convinence

Medically Needy Program

expand eligibilty to additional qualified persons who may have too much income to qualify under the categorically needy group

TemporarY Assistance For Needy FAmilies (TANF) makes cash assistance available for a limited time for children deprived of support because of a patient's

absence, death, incapacity, or unemployment

Tanf was previously called the

Aid to families with Dependent Children (AFDC) program

States are required to extend Medicaid eligibilty to all children born after Sept. 30 1983 who reside in families with

incomes at or below the federal poverty level, untill they reach age 19

State Children's Health Insurance Program also known as

SCHIP

BBA also known as

Balanced Budget Act

BBA allows states to

provide 12 mos. of continous Medicaid coverage (w/o reevaluation) for eligible children under age 19

Programs of all-inclusive care aka

PACE

Programs of all-inclusive care (pace) use a

capitated payment system to provide a comprehensive package of community-based services as an alternative to institutional care for persons age 55 or older who require a NURSING FACILITY LEVEL OF CARE

PACE is part of the

Medicaid program, but is an optinal service for Medicaid plans

When a PACE participant needs to use a

noncontract provider, physcician, or other entity, there is a limit on the amount that these noncontract entities can charge the PACE program

Community Spouse income is NOT

avalible to the spouse who resides in the facility, and the two individuals are not considered a couple for income eligibilty purposes

Medicare Catastrophic Coverage Act of 1988 (MCCA) implemented Spousal Improvershiment Protection Legislation in 1989 to prevent

married couples from being required to spend down income and other liquid assets (cash an property) before one of the partners could be declared eligible for Medicaid coverage for nursing facility care

MCCA

Medicare Catostrophic ACT

Eligibilty in many cases will depend on

the patient's monthly income

EARLY AND PERIODIC SCREENING DIAGNOSTIC TREATMENT SERVICES

EPSDT

EARLY AND PERIODIC SCREENING DIAGNOSTIC TREATMENT SERVICES consist of

routine pediatric checkups provided to all children enrolled in MEdicaid, including dental, hearing screening and vision services

Retroactive eligibilty is sometimes granted to patients whose ncome has fallen below the

state-set eligibilty level and wh had high medical expenses prior to filling for Medicaid

Inpatient hospital
(Medicaid eligibilty groups)

exluding inpatient services in institutions for mental disease

Outpatient hospital including Federal Qualified health Centers (FQHCs) and if
(Medicaid eligibilty groups)

permitted under state law, rural health clinic (RHC) and other ambulatory services provided by a rural health clinic that are otherwise included under states plans

Other labatory and
(Medicaid eligibilty groups)

x-ray

Certified pediatric and family nurse practitioners
(Medicaid eligibilty groups)

when liscensed to practice under state law

Nursing faciliy for services for
(Medicaid eligibilty groups)

beneficiares age 21 and older

Early and priodic screening, diagnosis, and treatment (EPSDT) for
(Medicaid eligibilty groups)

children under age 21

Family planning services and
(Medicaid eligibilty groups)

supplies

Physcian's
(Medicaid eligibilty groups)

services

Medical and surgical services
(Medicaid eligibilty groups)

of a dentist

Home health services for benficiaries entitled to a
(Medicaid eligibilty groups)

nursing facility services under the state's Medicaid plan

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