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established by the XIX social security act of 1965

CMS centers for medicare and medicaid

what medicaid is administered by

the social security administration

controls social security incomes

categorically needy individuals typically include which type of individuals

low income families with children
individuals receiving SSI
pregnant women, infants, and childrens with incomes less than a specified percent of the federal poverty level
qualified beneficiaries

spend down

the termed used for the process of depleting private or family finances to the point where the individual/family becomes eligible for medicaid assistance?

Program of All-inclusive Care for the Elderly

the program that provides comprehensive alternative care for noninstitutionalized elderly who otherwise would be in a nursing home

no less than one month

verifying medicaid eligibility

dual eligibles

aged or disabled individuals who are very poor are covered under the Medicaid and Medicare program which are commonly referred to


Medicare beneficiaries who qualify for certain Medicaid benefits if they have incomes below the FPL and resources at or below twice the standard allowed under the SSI program


when one state allows Medicaid beneficiaries from the other states to be treated in its medical facilities, this exchange of privileges

4 examples of third party liability

employment related health insurance
court ordered health insurance by noncustodial parent
worker's compensation
longterm care insurance

differences between medicaid and medicare

medicare provides insurance for disabled and people 665 years and older and pays for primary hospital care and related medically necessary services.
medicaid is needsbased healthcare program that pays for long term qualifying individuals.

list the federally mandated services specified in law that Medicaid must cover:

Inpatient hospital services
outpatient hospital services
prenatal care
vaccines for children
physician services


Medicare parts A and B are provided free of charge for qualifying individuals,


Part A covers custodial and long term care,


Neither Medicare part A nor part b covers and preventive care services,


For durable medical equipment to qualify for medicare payment, it must be ordered by a physician for use in the home, and items must be reusable

$131, 80%

the second cost sharing requirement in medicare part b is an annual deductible of blank after which medicare pays blank % of blank?
allowable charges


A form that medicare requires all healthcare providers to use when medicare does not pay for a service is the ?

provider sponsor organization

A group of medical providers that skips the insurance company middleman and contracts directly with patients


Local medical review policies (LMRPs) were replaced in 2003 by

self referring

some medicare healthmaintenance organization HMO enrollees are allowed to see specialists outside the network without going through a primary care physician is called?

MSP (Medicare secondary payer)

the term used when another insurance policy is primary to medicare

dual eligible

An individual qualifying for medicare and medicaid benefits


The program that provides community-based acute and long-term care services to medicare beneficiaries

A health insurance plan sold by private insurance companies to help pay for health care expenses not covered by medicare is called a?

supplemental policy

A private organization that contracts with medicare too pay part A and some part B bills and determines to payment to part A facilities is called a?

Fiscal intermediary

Medicare Part B helps pay for?

Medically necessary physician's services

Medicare pays what percent of allowable charges after the annual deductible is met?


benefit period

the duration of time during which a medicare beneficiary is eligible for part a benefits for services incurred in a hospital or skilled nursing facility or both?

Part A and B

Managed Healthcare plans that offer regular Medicare coverage and additional coverage for certain other services are called?

The prescription drug coverage plan, which began in January 2006 is called?

Medicare part D

The period during which a Medicare beneficiary is responsible for all prescription drug expenses until a total of 3850 is spent out of pocket is referred to as the?

Donut hole

Medicaid originally was created to give which individuals access to health care?

low income families

the medicaid program formerly referred to as aid to families with dependent children is now called?

TANF Temporary assistance for needy families

list some of the optional coverage that individual states can provide

intermediate nursing care
prescription drugs
hearing aids

list the services that categorically needy individuals must be provided with according to federal standards

inpatient hospital services
outpatient services
prenatal care
vaccines for children
lab and x ray

a health insurance plan sold by private insurance companies to help pay for expenses not covered by medicare is?


the individual responsible for initial MSP development activities formerly performed by Medicare FIs and carriers is called ?

COB contractor

the time period medicare allows for enrolling in a medicare supplement plan without penalty

open enrollment

list the various managed care choices included under medicare part c


THE balanced budget act of 1997 which went into effect in january 1999, expanded the role of private plans to include what type of plan?

managed care plans

medicare part c previously called what and renamed what by the medicare prescription drug, improvement and modernization act of 2003

medicare and choice renamed medicare advantage

list the common responsibilities of an fiscal intermediary

process claims
provide information for healthcare providers for the particular government program involved
generate guidelines for providers to faciliate the claims process
answer beneficiary questions about benefits, claims procession, appeals and the explanation of benefits document.

define and explain the function of a fiscal intermediary

processing and administering claims

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