38 terms

Ch. 15 (Medicaid)

Medical Assistance Program
passed by Congress in 1965
Title 19 of the Social Security Act
established a FEDERALLY mandated, but admininstered by the STATE
used in California
provides medical and health related services to certain individuals and families with low income
Medicaid Eligibility
To be eligible for federal funds, states are required to provide Medicaid coverge for certain individuals who recieve federally assisted income maintenance payments.
Medicaid Eligibility by State
each state administers its own Medicaid program, and CMS monitors the program
Medicaid programs must be available to the following "Mandatory Eligibility Groups"
1. Families who meet states Temporary Assistance for Needy Families (TANF) eligibility requirements that when into effect July 16, 1996
2. Pregnant women & children under age 6 whose income is at or below 133% of federal poverty level.
Temporary Assistance for Needy Families (TANF)
makes cash assistance available, for a limited time, for children deprived of support because of a parent's absence, death incapacity, or unemployment.
previously called the AID to Families with Dependent Children AFDC program
Required in every state
to extend Medicaid eligibility to all children born after Sept. 30, 1983, who reside in families with incomes at or below the federal poverty level, until they reach age 19.
State Children's Health Insurance Program
also known as (SCHIP) was implemented in accordance with the Balanced Budget Act (BBA).
State Children's Health Insurance Program
allows states to create or expand existing insurance programs, providing more federal funds to states for the purpose of expanding Medicaid eligibility to include a greater number of currently uninsured children.
BBA allows states to
provide 12 months of continous Medicaid coverage (without reevaluation) for eligible children under the age of 19.
is part of the Medicare program, but is an optional service for state Medicaid plans.
When PACE participants need to use noncontract provider, physician or other entitiy....
there is a limit on the amount that these noncontract entities can charge the PACE program
Spousal Impoverishment Protection
the community spouse's income in NOT available to the spouse who resides in the facility and the 2 individuals are not considered a couple for income eligibility purposes.
Eligibility in many cases depend on....
patient's monthly income.
Confirmation of eligibility
should be obtained for each visit, be sure to access the Medicaid verification line.
Retroactive eligibility
sometimes granted to patients whose income has fallen below the state-set eligibility level and who had a high medical expenses prior to filing for Medicaid.
Early Periodic Screening, Diagnostic and Treatment (EPSDT) Services
consist of routine pediatric checkups provided to all children enrolled in Medicaid including dental, hearing screening and vision services.
Services for the Needy Eligibility Groups
1. inpatient hospital
2. outpatient hospital (including federally Qualified health centers, rural health clinic (RHC) and other ambulatory services
5. nursing facility services for beneficiaries age 21 and older
6. Early and periodic screening, diagnosis and treatment (EPSDT) for children under age 21
7. Family planning services and supplies.
8. Physician's services
Preauthorization guidelines include:
1. elective inpatient admission
vendor payment program
which means that states pay healthcare providers on a fee-for service basis or states pay for medicaid services using prepayment arrangements.
Medicaid makes payment directly to providers....
those participating in Medicaid must accept the reimbursement as payment in full.
States CAN
require nominal deductibles, coinsurance, or copayments for certain services performed for some Medicaid recipients.
Emergency & Family Planning Services
are exempt from copayments.
Federal Medical Assistance Percentage (FMAP)
its a portion of the Medicaid program paid by the federal government.
Facilities of the Indian Health Services
federal government also reimburses states for 100 percent of the cost of services provided through these facilities.
Dual eligibles
individuals entitled to Medicare and eligible for some type of Medicaid benefit (abbreviated as Medi-Medi).
Individuals eligible for full Medicaid coverage
receive program supplements to their Medicare coverage via services and supplies available from the state's Medicaid program.
Services that are covered by both programs
are paid FIRST by Medicare and the difference by Medicaid.
Medicaid eligibility verification system (MEVS)
sometimes called recipient eligibililty verification system or REVS) allows providers to electronically access the state's eligibility file
Providers receive reimbursement
from Medicaid on a lump sum basis, which means they will receive payment for several claims at once.
Medicaid remittance advice
is sent to a provider which contains the current status of all claims
voided claim
a deduction from the lump sum payment made to the provider.
Surveillance and Utilization review subsystem (SURS)
A federal regulation that requires Medicaid to establish and maintain safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services.
Medical Necessity & Covered Services:
1. consistent with the pt's symptoms, diagnosis, condition or injury.
2. recognized as the prevailing standard and consistent with generally accepted professional medical standards.
mother/baby claim
is submitted for services provided to a baby under the mothers' Medicaid ID number.