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