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Medicaid.
| Question | Answer |
|---|---|
| What year was Medicaid established? | 1965 |
| What is Medicaid? | a federally mandated, state-administered medical assistance program for individuals with incomes below the federal poverty level |
| MediCal | California's Medicaid program |
| MassHealth | Massachusetts Medicaid program |
| TennCare | Tennessees Medicaid program |
| What does medically indigent mean? | someone with low income and limited resources |
| Who funds Medicaid programs? | the federal and state governments |
| True or False: A person eligible for Medicaid in Michigan is eligible in Ohio | False: Every states eligibility requirements differ |
| "state-only" programs | programs to provide medical assistance for specified persons who do not qualify for Medicaid |
| What are the 3 Medicaid eligibility groups? | 1. Categorically needy 2. Medically needy 3. Special groups |
| What qualifies someone as categorically needy? (5) | 1. Families who meet TANF eligibility requirements 2. Pregnant women & kids under 6 @ or below 133% poverty level 3. Caretakers for kids under 18 4. SSI recipients 5. Individual/couples living in med institutions w/monthly income up to 300% of SSI inc |
| TANF | Temporary Assistance for Needy Families, previously AFDC |
| AFDC | Aid to Families with Dependent Children, replaced by TANF |
| What does TANF provide? | cash assistance, for a limited time, for children deprived of support because of a parent's absence, death, incapacity, or unemployment |
| What qualifies someone as medically needy? | They make just over the income qualifications for Medicaid, but they are allowed to pay a monthly premium and "spend down" their monthly deductible |
| Who are states required to cover under a medically needy program? | 1. pregnant women through 60-days postpartum 2. children under 18 3. certain newborns for one year 4. certain protected blind persons |
| What are the 3 types of special groups that are eligible for Medicaid? | 1. Dual eligible 2. working disabled 3. time limited |
| What does dual eligible mean? | patient is eligible for Medicaid and Medicare |
| What are the 4 types of dual eligibility? | 1. QMB: Qualified Medicare Beneficiaries 2. QWDI: Qualified working disabled individuals 3. QI: Qualifying individual 4. SLMB: Specified low-income Medicare beneficiary |
| QMB | Qualified Medicare beneficiaries |
| Qualified Medicare beneficiaries | state pays Medicare premiums, copays, and deductibles. must be at or below 100% of poverty level and resources at or below 2x standard allowed under SSI |
| QWDI | Qualified working disabled individuals |
| Qualified working disabled individuals | state pays Part A Medicare premiums. income below 200% of the federal poverty level and resources that are no more than 2x the standard allowed under SSI |
| QI | Qualifying individual |
| Qualifying individual | state pays Medicare Part B premiums. incomes between 120% and 175% of the federal poverty level |
| SLMB | specified low-income Medicare beneficiary |
| specified low-income Medicare beneficiary | state pays Medicare Part B premiums. income between 100% and 120% of federal poverty level |
| Qualifications for working disabled (2) | 1. working disabled people age 16-65 w/income and resources greater than that allowed under SSI program 2. Working individuals who become ineligible for the group above because their medical condition improves (may be required to share in the cost) |
| Time limited eligibility (2) | 1. women who have breast or cervical cancer 2. uninsured TB patients |
| SCHIP | State Children's Health Insurance Program |
| presumptive eligibility period | Patient is treated under the assumption that they will qualify for Medicaid and assistance is given to apply |
| How far back can Medicaid coverage begin? | 3 months prior to time of application |
| How often should Medicaid coverage be verified? | Every visit because eligibility is determined on a monthly basis |
| community spouse | spouse still living at home while the other spouse is in a nursing facility |
| What possessions are protected by the spousal impoverishment program? | the couples home, household goods, automobile, some money and burial funds |
| What are the 3 ways to check eligibility? | 1. by phone 2. online 3. POS device |
| EPSDT | Early and Periodic Screening, Diagnostic, and Treatment services |
| What are examples of EPSDT services? | 1. pediatric checkups 2. dental checkups 3. hearing and vision screenings |
| Services for categorically needy groups | 1. hospital 2. labs and xrays 3. nursing facility for beneficiaries 21 and older 4. EPSDT for under 21 5. family planning services & supplies 6. physician services 7. dental due to injury 8. DME 9. Mid-wife/pregnancy services 10. postpartum care |
| Services for medically needy groups | 1. prenatal and delivery services 2. postpartum services for beneficiaries under 18 3. home health services to those entitled to receive nursing facility services |
| What services are exempt from copayments? | 1. family planning 2. emergency |
| FMAP | Federal Medical Assistance Percentage |
| federal medical assistance percentage | portion of the Medicaid program paid by the federal government, calculated annually. Wealthier states get less |
| Name 4 additional benefits available to those with QMB and Medicare coverage | 1. nursing facility beyond the 100-day limit 2. prescription drugs 3. eyeglasses 4. hearing aids |
| what does payer of last resort mean? | Medicaid is always the last insurance to pay on a claim. |
| balance billing | billing a patient for the balance between what Medicaid paid and their normal billing price |
| MEVS | Medicaid eligibility verification system |
| REVS | recipient eligibility verification system |
| Medicaid remittance advice | tells current status of all claims |
| adjusted claim | has a payment correction, resulting in additional payment to the provider |
| voided claim | Medicaid shouldn't have originally paid, results in a deduction for the lump-sum payment made to the provider |
| How long should remittance advice be maintained according to the statute of limitations? | Varies state to state, 7 years in MI |
| SURS | surveillance and utilization review subsystem |
| surveillance and utilization review subsystem | surveys are sent out to patients to verify services were rendered. This is to protect against fraud |
| medical necessity | 1. treatment is consistent with medical problem 2. consistent with generally accepted medical standards 3. provided in response to a life threatening condition, pain, injury, illness, infection |
| When are medically necessary services provided? | 1. not at time of convenience for the provider or recipient 2. when there is no other equally effective course of treatment available or suitable |
| Who is Medicaid's fiscal agent? | Varies state to state, in MI DHS (dept of human services) |
| What is the deadline for filing a Medicaid claim? | Varies state to state, in MI it is 1 year |
| Who determines the reimbursement schedule? | each state |
| Do Medicaid patients have deductibles? | Some do, those in a spend down program |
| Do Medicaid patients have copayments? | Some do |
| Are preauthorizations required for nonemergency hospitalization? | yes |
| subrogation | the assumption of an obligation for which another party is primarily liable |
| What must be attached with the CMS-1500 claim form for all Medicaid claims? | remittance advice from any other insurance coverage |
| mother/baby claim | a claim submitted for services provided to a baby under the mother's Medicaid id number. Only good for the first 10 days after baby is born |
| Who monitors Medicaid? | CMS |
Created by:
StephanieCremeans