Chapter 15 Medicaid Copyright 2008 Delmar Learning All

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Chapter 15 Medicaid Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 15 Medicaid Copyright © 2008 Delmar Learning. All rights reserved.

Introduction • Medicaid helps in providing medical and health related services to families with

Introduction • Medicaid helps in providing medical and health related services to families with limited resources or low income. 2 Copyright © 2008 Delmar Learning. All rights reserved.

Under Broad Federal Guidelines • States can: – Establish their own eligibility standards –

Under Broad Federal Guidelines • States can: – Establish their own eligibility standards – Determine type, amount, duration, and scope of services – Set rates of payment for services – Administer their own program 3 Copyright © 2008 Delmar Learning. All rights reserved.

Medicaid Eligibility • Medicaid is limited to individuals who fall into specified categories: –

Medicaid Eligibility • Medicaid is limited to individuals who fall into specified categories: – Pregnant women and resultant newborn children – Children and teens up to ages 18 or 21 – Depends on the state’s requirements 4 Copyright © 2008 Delmar Learning. All rights reserved.

Medicaid Eligibility • Aged, blind, or disabled people who have low income • Age

Medicaid Eligibility • Aged, blind, or disabled people who have low income • Age 65 or older: – Terminally ill who want hospice – In a nursing facility and have low income – Aged, blind, or disabled and need a nursing facility but can stay at home and get care 5 Copyright © 2008 Delmar Learning. All rights reserved.

Medicaid Eligibility • Individuals eligible for Medicare and have low income and limited resources

Medicaid Eligibility • Individuals eligible for Medicare and have low income and limited resources • People who qualify for welfare • Families with children under the age of 18 • People who cannot pay high medical bills 6 Copyright © 2008 Delmar Learning. All rights reserved.

Special Groups States Must Assist • • Qualified Medicare beneficiaries Qualified working disabled individuals

Special Groups States Must Assist • • Qualified Medicare beneficiaries Qualified working disabled individuals Qualifying individual Specified low-income Medicare beneficiary 7 Copyright © 2008 Delmar Learning. All rights reserved.

State Children’s Health Insurance Program • “The State Children’s Health Insurance Program was implemented

State Children’s Health Insurance Program • “The State Children’s Health Insurance Program was implemented in accordance with the balanced Budget act, which 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. ” 8 Copyright © 2008 Delmar Learning. All rights reserved.

Mandatory Services • • Inpatient hospital services Outpatient hospital services Physician services Nursing facility

Mandatory Services • • Inpatient hospital services Outpatient hospital services Physician services Nursing facility services for individuals aged 21 and up 9 Copyright © 2008 Delmar Learning. All rights reserved.

Mandatory Services • Home health services for persons eligible for skilled nursing services •

Mandatory Services • Home health services for persons eligible for skilled nursing services • Family planning services and supplies • Prenatal care • Rural health clinic services • Laboratory and x-ray services 10 Copyright © 2008 Delmar Learning. All rights reserved.

Mandatory Services • Federally qualified health center and ambulatory services offered by and FQHC

Mandatory Services • Federally qualified health center and ambulatory services offered by and FQHC • Early and periodic screening, diagnostic, and treatment services and immunizations for individuals under age 21 11 Copyright © 2008 Delmar Learning. All rights reserved.

Additional Services • Nursing facility care beyond the 100 -day limit covered by Medicare

Additional Services • Nursing facility care beyond the 100 -day limit covered by Medicare • Prescriptions drugs • Eyeglasses • Hearing aids 12 Copyright © 2008 Delmar Learning. All rights reserved.

Medical Necessity • Consistent with the recipient's symptoms, diagnosis, condition, or injury • Recognized

Medical Necessity • Consistent with the recipient's symptoms, diagnosis, condition, or injury • Recognized as the prevailing standard and consistent with generally accepted medical standards • Provided in response to a lifethreatening condition 13 Copyright © 2008 Delmar Learning. All rights reserved.

Billing Notes • Fiscal agent – Will vary from state to state • Underwriter

Billing Notes • Fiscal agent – Will vary from state to state • Underwriter – Is shared between the state and federal governments • Form used – CMS-1500 14 Copyright © 2008 Delmar Learning. All rights reserved.

Billing Notes • Timely filing deadline – Check with your state’s Medicaid office •

Billing Notes • Timely filing deadline – Check with your state’s Medicaid office • It is important to file as soon as possible 15 Copyright © 2008 Delmar Learning. All rights reserved.

Billing Notes • Allowable determinations – Maximum reimbursement for each nonmanaged care service •

Billing Notes • Allowable determinations – Maximum reimbursement for each nonmanaged care service • Accept Assignment – Must be selected on the CMS-1500 • Deductibles – Are not always required 16 Copyright © 2008 Delmar Learning. All rights reserved.

Billing Notes • Copayments – Required for some Medicaid recipients • Inpatient Benefits –

Billing Notes • Copayments – Required for some Medicaid recipients • Inpatient Benefits – Nonemergency must be preauthorized 17 Copyright © 2008 Delmar Learning. All rights reserved.

Mother and Baby • For the first 10 days of the infant’s life –

Mother and Baby • For the first 10 days of the infant’s life – Mother’s Medicaid identification number is used 18 Copyright © 2008 Delmar Learning. All rights reserved.