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37 terms

medicaid ch 15 part 1

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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