Chapter 8: Understanding Medicaid



Understanding Medicaid

I. What is Medicaid?: a combination of federal and state medical assistance program designed to provide comprehensive medical care for low income families

a. Special emphasis: children, pregnant women, the elderly, the disabled, and parents with dependent children who have no other way to pay for healthcare

b. Established: under Title 19 of the Social Security Act of 1965

c. Federal government and state: share the cost; the state administers or runs the program

d. State to state: benefits vary

II. Evolution of Medicaid

a. Original creation: to give low-income Americans access to healthcare

b. Today: it’s a major social welfare program administered by CMS

III. Structure of Medicaid

a. Federal government’s role: established broad national guidelines; individually must fall into a designated group before they are eligible; see Fig 8-2

b. State’s options: required to provide Medicaid coverage for certain people who receive federally assisted income-maintenance payments and for related groups snot receiving cash payments; must cover categorically need people, but have options on how they define it

i. Categorically needy usually includes

1. low income families with children

2. individuals receiving SSI

3. pregnant women, infants, and children with incomes less than a specified percent to the FPL (federal poverty level)

4. qualified Medicare beneficiaries

c. Mandated Services: to receive federal funds, states must offer these

i. Inpatient and outpatient hospital services

ii. Physician services

iii. Medical and surgical dental services

iv. Nursing facility services for individuals age 21 or older

v. Home healthcare for individuals eligible for nursing facility services

vi. Family planning services and supplies

vii. Rural health clinic services and any other ambulatory services offered by a rural health clinch that are otherwise covered under the stae plan

viii. Lab and x-ray services

ix. Pediatric and family nurse practitioner services

x. Federally qualified health center services

xi. Nurse-midwife services

xii. Early and periodic screening, diagnosis, and treatment for individuals younger than 21

d. optional services: state can provide as many or as few as they choose

e. state children’s health insurance program (SCHIP): allows states to expand their Medicaid eligibility guidelines to cover more categories of children

f. Fiscal Intermediaries: processes all healthcare claims on behalf of the Medicaid program

IV. Who Qualifies For Medicaid Coverage?

a. Categorically needy: Figure 8-2

b. Medically needy: may meet categorically needy category, but exceed income; must spend down or pay a share of their medical costs; coverage of their group is optional under federal law

c. Program of All-Inclusive Care for the Elderly (PACE): provides comprehensive alternative care for noninstitutionalized elderly who otherwise would be in a nursing home

V. Payment for Medicaid Services: paid directly to provider; provider must accept as payment in full

a. Cost sharing: states can impose deductibles, copayments and coinsurance for some services with the exception of emergency care and family planning

i. Certain people must be excluded from cost sharing: pregnant women, children younger than 18, hospital or nursing home patients, categorically needy HMO enrollees

ii. Medically necessary: Medicaid will only pay for services that are determined medically necessary; if you’re not sure if a procedure is medically necessary, check the Medicaid provider handbook or contact the fiscal intermediary; always do this before the procedure is performed to ensure payment

iii. Prescription drug coverage: all states cover prescription drugs for certain categorically needy patients

iv. Accepting Medicaid patients: provider has the right to accept or reject Medicaid patients; they can limit the number of Medicaid patients they accept as long as there isn’t any discrimination; if a patient has Medicare and Medicaid and the provider doesn’t accept Medicaid, the patient must know before the appointment

v. Participating providers: must agree to accept what Medicaid pays as payment in full; if patient wants to be treated for a non-covered service, the patient must sign a waiver stating they are aware it is a non-covered service and they will be responsible

VI. Verifying Medicaid Eligibility

a. When should this be done?: before every appointment

b. Several methods

i. Using patient ID card: check for dates on the card

ii. By phone—using touch tone or voice automated system

iii. Using Electronic Data Interchange (EDI): could be online database

iv. Point of Sale device: swipe card on credit card type machine

v. Computer software program

c. Benefits of Eligibility Verification System: reduces the number of denied claims, submission of more accurate claims; decreases eligibility related claims denial

VII. Medicare/Medicaid Relationship

a. Dual coverage: receive Medicare coverage, but also receive Medicaid for some services

b. Special Medicare/Medicaid Programs

i. Qualified disabled and working individuals: lose Medicare benefits because they return to work. They are eligible to purchase Medicare hospital insurance

ii. Supplemental medical insurance: premiums not paid by Medicaid

iii. Specified low-income medicare beneficiaries: Medicaid will not pay for Medicare hospital insurance for this group

iv. Payer of last resort: all other available 3rd party resources must meet their legal obligation to pay claims before the Medicaid program pays for care of an individual eligible for Medicaid

v. Medicare and Medicaid differences explained

1. medicare isn’t tied to need: it’s an entitlement program because you pay taxes for it

VIII. Medicaid claim

a. Medicaid simple claim: Medicaid coverage only; no secondary insurance (Figure 8-4), (Figure 8-5) is for secondary

b. Reciprocity: one state allows Medicaid beneficiaries from other states to be treated in its medical facilities (usually happens with neighboring states)

IX. Special Billing Notes

a. Time Limit for Filing Medicaid claims: varies from state to state; always file ASAP

b. Copayments: usually for podiatrist, dentists, and chiropractors; if you work for one of these doctors, you should check the Medicaid guidelines for your state

c. Accepting assignment: block 27 on CMS-1500 must be checked yes or claim may be denied

d. Preauthorization: for all hospitalization unless it was an emergency; in the case of emergency, most states require 24 hour notice; preauth # should be entered in block 23 of the CMS-1500

e. Retention, Storage, and Disposal of Records

i. HIPPA: 6 years

ii. Federal law: criminal or civil action can be taken in up to 7 years

iii. Privacy Act of 1974: kept indefinitely

iv. Can be kept on paper (least efficient), microfiche, CD-ROM or other storage devices

X. Fraud and Abuse in the Medicaid System

a. What is Medicaid fraud?: drives up costs; what are some examples

b. Patient abuse and neglect: what are some indicator of abuse?

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download