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MAA102 Week 5 8 & 9

When was Medicaid established? 1965 under the Social Security Act
What is a medical assistance program funded by the US federal and state governments that's designed to provide quality and comprehensive medical care for people who are unable to pay some of their own medical expenses? Medicaid
Which groups of people does Medicaid place special emphasis on? Children, pregnant women, elderly, disabled, and parents with dependent children who do not have another way to pay for healthcare
Do Medicaid benefits vary from state to state? Yes
What is the CMS? Centers for Medicare and Medicaid Services
Who administers the Medicaid program? Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services (HHS)
What are the Medicaid mandatory benefits/services related to pregnancy, womens' and children's health ? Nurse midwife, family planning, licensed/state recognized certified pediatric & family nurse practitioner, licensed/state recognized freestanding birth center, tobacco cessation counseling for pregnant women
What is EPSDT? Early and Periodic Screening, Diagnostic, and Treatment Services
What are some Medicaid mandatory benefits/services that are not specifically for women, pregnancy, and children? Inpatient/outpatient hospital, EPSDT, Nursing facility, Home health, Physician, rural health clinic, federally-qualified health center, laboratory & xray, transportation to medical care, tobacco cessation
What should a health insurance professional do if they question the medical necessity of a procedure? They should consult the current Medicaid provider handbook provided by the state in which they're employed, or phone the contractor that administers local Medicaid programs.
When should a health insurance professional consult their current state Medicaid handbook or phone a local medicaid contractor regarding the medical necessity of a procedure? Before the service or procedure is performed in order to avoid problems collecting payment from the patient or Medicaid after the fact
What is Medicaid's general rule about payment for procedures and services? Medicaid only pays for services that are determined to be medically necessary
How does Medicaid determine if a procedure/service is medically necessary? Consistent w/diagnosis, in accordance, performed at proper level, provided in the most appropriate setting, reasonable/necessary for diagnosis/treatment of illness/injury, improve the functioning of a malformed body part
What is a term that describes beneficiaries who have both Medicare and Medicaid coverage and how does their coverage work? Dual Eligibles. Medicare does not pay for all health services. Medicare beneficiaries have to: Meet a yearly deductible, pay a monthly premium and pay a 20% copayment (cost sharing) for all covered services
Does Medicaid currently provide prescription drug coverage for more than 6 million Medicare beneficiaries? No
How often should you verify Medicaid eligibility? Every month in which the patient visits the practice, because most states grant Medicaid eligibility a month at a time.
What should Medicaid providers do before providing service? Always make sure that Medicaid will pay for patients' medical care, determine eligibility for the current date, and discover any limitations to the recipient's coverage
What is the "payer of last resort?" All other available third-party resources must meet their legal obligation to pay claims before the payer of last resort pays for the patient's care
In which cases is Medicaid the payer of last resort? All cases
What do Medicaid hospitalization preauthorizations sometimes require? Copay
What do most states usually require for Medicaid inpatient hospitalization? 24-hour preauthorization
What do most Medicaid contractors require in the case of emergency inpatient hospitalization? 24-hour notification after the emergency visit, as appropriate
Who administers Medicare? Centers for Medicare and Medicaid Services (CMS)
What is FICA? Federal Insurance Contributions Act is the Federal system of old age, survivor, and disability insurance, Financed by Social Security taxes
Medicare is not free! In which forms do beneficiaries pay for part of the cost? Premiums, Deductibles, and Coinsurance
How many primary parts does Medicare have? 4
What are the primary parts of Medicare? Part A: Hospital insurance, Part B: Medical (physician's care) insurance, Part C: Medicare Advantage, Part D: Prescription drug program
Which part of Medicare pays for the medically necessary services for these types of healthcare; Inpatient hospital care, Inpatient care in a skilled nursing facility (SNF), Home healthcare, Hospice care, Blood (transfusions, etc.) Part A
Which 2 groups of people are eligible for free Part A Medicare? People 65 and older who are eligible to receive a monthly Social Security benefit and eligible based on wages on which sufficient Medicare payroll taxes were paid. Also, any disabled individual younger than 65 who meets eligibility requirements.
What is a private organization that contracts with Medicare to pay Part A and some Part B bills, and determines payment to Part A facilities for covered items and services provided by the medical facility? Medicare Administrative Contractors (MACs)
Which part of Medicare is financed by federal government funds and beneficiary premiums, pays for medically necessary physicians’ services; some preventive services, outpatient hospital services, durable medical equipment (DME), and blood? Part B
Which Medicare part has a premium and how is it paid? All beneficiaries pay for Part B coverage. Monthly premium changes every year. Premium is deducted from the beneficiary’s monthly Social Security benefits check.
When can individuals enroll in Medicare Part A and/or B? Individual must decide whether to enroll in Part A and/or Part B, beneficiaries should contact local Social Security office 3 months before 65th birthday
What are the penalties for late enrollment in Medicare Part A and B? Higher premiums
What are the exceptions to penalties for late enrollment in Medicare Part A and B? Still covered by an employer's group health plan at the time of eligibility, and can avoid late enrollment penalty by enrolling in one of Medicare’s Advantage Plans
What are fees that Medicare permits for a particular service or supply? allowable charges
What are the Part B Premium and cost-sharing requirements? Beneficiaries must pay annual deductible, Medicare pays 80% of allowable charges after deductible is met
What part of Medicare consists of Medicare Advantage (MA) plans; Medicare managed care plans (e.g., HMOs, PPOs, PSOs), Medical private, unrestricted, fee-for-service plans, and Medical savings accounts (MSAs) ? Part C
What part of Medicare includes both Part A and Part B coverage, plus additional services not included under original Medicare, such as: Preventive care, Prescription drugs, Eyeglasses, Dental care, and Hearing aids? Part C
What part of Medicare provides prescription drug coverage and has additional premiums? Part D
What are the 2 ways to get prescription drug coverage through Medicare Part D? Prescription drug plans (sometimes called PDPs) that add drug coverage to original Medicare, some Medicare Cost Plans, some Medicare PFFS plans, MSA plans, Medicare Advantage Plans, or other Medicare plans
How does Medicare Part D work for Dual Eligibles? Lose their prescription drug coverage under Medicaid , can enroll in Medicare Part D, Medicare pays Part D deductible and premiums for dual eligibles if enrolled in average or low-cost Part D plans
What is Program of All-Inclusive Care for the Elderly? PACE is Community-based acute and long-term care services, eligible for, 55 years old or older, meets the medical need criteria, lives in an area serviced by a PACE organization, can be safely served in the community according to the PACE organization
What is Medicare/Medicaid Dual Eligibility? Individuals who qualify for benefits under both the Medicare and Medicaid programs. Medicare beneficiaries have to meet a yearly deductible, pay a monthly premium, and pay a 20% copayment (cost sharing) for all covered services
What insurance supplements Medicare benefits, regulated by federal and state law, policy must be clearly identified as Medicare supplemental insurance, and must provide specific benefits that help fill the gaps in Medicare coverage? Medigap Insurance
What is the eligibility requirement for Medigap? Medicare beneficiaries have a 6-month open enrollment period
Why is it important for healthcare professionals to know about Medicare? You will be a liaison between many third-party payers and the entire healthcare team, you must be able to answer patients’ questions about Medicare accurately, you must also become an expert from the beneficiaries’ perspective
How does the CMS determine Medicare fee payments? Resource-based relative value system (RBRVS)
What are the rules for how Medicare pays PARs? Medicare PARs agree to accept Medicare's allowed amount as payment in full. Medicare pays 80% of the allowed amount, Medicare PARs cannot balance bill
What are the exceptions to Medicare's mandatory electronic submission for claims? Small provider claims; claims from providers submitting less than 10 claims per month
What are three triggers for Medicare audits? Downcoding , using the same code repeatedly, and Patient complaints
What is a physician review of medical records? Physician reviewers conduct medical record review to determine whether the care received was medically necessary and appropriate, reviews may include utilization, coding, or quality-of-care issues
What is PQRS? Physician Quality Reporting System provides a financial incentive to eligible professionals (EPs) for voluntarily reporting data on specific quality measures for covered services furnished to Medicare beneficiaries
What are some examples of Medicare billing fraud? Billing for tests or procedures that were never done, billing for a more complicated procedure than was actually done, and billing a multiple-procedure operation as if several separate procedures were performed
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