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Chapter 15
Question | Answer |
---|---|
Medicaid eligibility is limited to people who fall into three coverage groups | 1) Medically needy 2) Categorically needy 3) Special groups |
Medicaid provides | medical and health-related services to individuals and families with low incomes ( indigent) |
Spousal Impoverishment Protection Legislation of 1989 | prevents married couples from being required to spend down income and other liquid assets before one of partners could be declared eligible for nursing care coverage |
Medically necessary services | are not provided for the sake of anyone's convenience, regardless of whether it is the doctor or patient |
TANF | Temporary Assistance to Needy Families |
States are required to | extend Medicaid eligibility to all children born after 9/30/83 until they are 19 years old |
TANF makes cash assistance available, for | a limited time, for children deprived of support due to parent's absence, death, incapacity or unemployment |
TANF was previously known as | AFDC (Aid to families with Dependent Children ) |
SCHIP | State Children's Health Insurance Plan |
SCHIP allows states to | create or expand existing insurance programs and provides more federal funds to states for the purpose of expanding Medicaid eligibility to include a greater number of children who are currently uninsured |
Medi-Cal | is California's equivalent to the Medicaid program |
Medicaid began in | 1965 |
Surveillance Utilization Review System | Safeguards against unnecessary or inappropriate use of Medicaid services or excess payments and assesses the quality of those services |
States are required to | provide Medicaid coverage for people who receive federally assisted income-maintenance payments |
Preauthorization guidelines | include elective inpatient admission |
States may require | small deductibles, coinsurance or copayments for certain services performed |
Services covered by both Medicaid and Medicare? | Medicare pays first and Medicaid pays the difference. Medicaid is ALWAYS the payer of last resort |
In many cases, Medicaid eligibility will depend on | the patient's monthly income |
Medicaid is | jointly funded by the state and federal governments |
Each state administers it's own Medicaid program and the | CMS (Centers for Medicare and Medicaid Services) monitors the programs |
Categorically needy Medicaid eligibility groups are not | necessarily entitled to nursing facility services for individuals under age 21 |
The BBA allows | states to provide 12 months of continuous Medicaid coverage (without reevaluation) for eligible children under the age of 19 years old |
Medicaid operates as | a vendors and fee for service payment system |
Medicaid-covered services must be recognized as | the prevailing standard and consistent with generally accepted professional medical standards of the provider's peer group |
Providers receive reimbursement from | Medicaid on a lump sum basis- several claims are paid at on time |
Retroactive eligibility | is sometimes granted to patients who had high medical expenses before filling for Medicaid |
Emergency and Family Planning services are | exempt from copayments |
There is a limit on | the amount that a non-contract provider, physician, or other entity can charge a PACE participant |
Medicaid PARs ( participating providers) | have to accept the Medicaid payment as payments in full |
The Medicaid Eligibility Verification System | allows providers to electronically access the state eligibility file |
States must provide | home health services to beneficiaries who are entitled to receive nursing facility services |
Federal Medical Assistance Percentage | the portion of the Medicaid program paid by the federal government |
Dual eligible | refers to individuals entitled to Medicare and eligible for some type of Medicaid services |
The federal government reimburses states | 100% of the cost of services provided through facilities of the Indian Health Service |
Spend down to Medicaid eligibility is | used for the medically needy |
EPSDT | routine pediatric checkups for all children enrolled in Medicaid |
Mother/baby claim refers to | services provided to a baby under the mother's ID number |
PACE | alternative care for people 55 or older who require nursing facility level care |
Community Spouse | spouse who is not in nursing home |
Voided claim | a deduction is taken from the lumps-sum payment made to provider |
Medicaid Remittance Advice | Shows the current status of all claims |
MCCA | prevents married couples from being required to spend down |