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Chapter 15

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
Created by: drea08