Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Chapter 13 Medicaid and Other State Programs Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Describe the benefits and nonbenefits of Medicaid. Define terminology inherent to Medicaid. Interpret Medicaid abbreviations. Name the two Medicaid eligibility classifications. List important information to abstract from the patient’s Medicaid card. State eligibility requirements and claims procedures for the Maternal and Child Health Program. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Learning Objectives (cont’d.) Identify those eligible for the Medicaid Qualified Medicare Beneficiaries program. Explain basic operations of a Medicaid-managed care system. Describe basic Medicaid claim procedure guidelines. File claims for patients who have Medicaid and other coverage. Minimize the number of insurance forms rejected because of improper completion. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Chapter 13 Lesson 13.1 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Medicaid (MCD) History Federal Emergency Relief Administration Social Security Act 1950—state programs Deficit Reduction Act (DEFRA) Fiscal Responsibility Act (TEFRA) Medi-Cal Review federal legislative activity leading to Medicaid. Discuss state and federal coordination of assistance. (Medicaid is administered by state governments with partial federal funding; coverage varies by state, but the federal government sets minimum requirements) Discuss Medi-Cal (as appropriate). Explain what federal law provides for a program of medical assistance for certain low-income individuals and families, and give the year it was enacted. (Title XIX of the Social Security Act – 1965) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Maternal and Child Health Program (MCHP) Provide low-income mothers and children with quality care Reduce infant mortality Increase child immunizations Pregnancy care MCHP provides federal funds to states to enable them to: provide access to quality maternal and child health services. reduce the incidence of preventable diseases and handicapping conditions among children. increase the number of low-income children receiving health assessments and follow-up diagnostic and treatment services. provide prenatal, delivery, and postpartum care for low-income children. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Maternal and Child Health Program (MCHP) (cont’d.) Preventive care Rehabilitation Special needs MCHP provides federal funds to states to enable them to: Provide preventive and primary care services for low-income children. Provide rehabilitation services for the blind and disabled younger than 16 years of age. Provide, promote, and develop family-centered, community-based, coordinated care for children with special health care needs. What types of medical specialties most often service those patients in MCHP? Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Low-Income Medicare Programs MQMB (QMBs): The Medicaid Qualified Medicare Beneficiary program SLMB (SLMBs): The Specified Low-Income Medicare Beneficiary or SLMB QI: Qualifying individuals QMBs (kwim-bees): Elderly and disabled below the poverty line. They pay Medicare Part B premiums, deductibles, and copays. SLMB (slim-bee): Explain who is eligible for SLMB, what expenses are paid by the program, and what expenses are paid by the individual. (elderly who are 20% above the federal poverty line; SLMB pays the Part B premium, and the patient pays Part B deductibles, copays, and noncovered items) QI: They may be 135% above the poverty line (but less than 175%). QI pays the premium. Discuss what administrative system(s) could be used to ensure collection of the correct copays and deductibles from low-income Medicare patients. (Answers will vary.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Medicaid Eligibility Categorically needy Medically needy Accepting Medicaid patients Point-of-service machine Retroactive eligibility Explain who is eligible for Medicaid. (elderly [65+], blind, disabled, members with dependent children with minimal support, low income/resources. See Box 13.1 [p. 473].) Define “categorically needy.” (Aged, blind, or disabled individuals or families and children who meet financial eligibility requirements) Define “medically needy.” (Persons in need of financial assistance of whose income and resources will not allow them to pay for the costs of medical care) Describe what steps should be taken to verify eligibility, and explain why verification is so important when accepting Medicaid patients. (See Box 13.1 [p. 473] for eligibility requirements.) Explain how a point-of-service machine works. (POS machine connects to state system to verify Medicaid coverage using information from a card) Define “retroactive eligibility”, and explain how it should be managed in the medical office. (A patient that receives medical care while applying for Medicaid should be treated as a cash patient; once Medicaid approves eligibility and sets a retroactive date for coverage, the patient should be reimbursed for any costs that will be billed to Medicaid.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Health Insurance Card Become familiar with the Medicaid card that patients will present. Explain why the card itself isn’t proof of eligibility. (state requirements, expiration dates, and changing conditions may affect eligibility and may not be reflected on the card) Explain how the information on the card (or patient registration form) should be used to verify eligibility. (patient’s name, Medicaid ID number, gender, and date of birth should be used to confirm eligibility and submit claims to Medicaid.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Medicaid Benefits Covered services Disallowed services Explain what types of services are covered under Medicaid and describe the types of medical practices and settings in which these services are performed. (See Box 13.2 [p. 477] for a list of covered services) Discuss what actions should be taken if a service is disallowed. (The physician can bill the patient in most states, if a service is disallowed by Medicaid.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Claim Procedure Copayment Prior approval Some complexities are related to Medicaid claim procedures, and the specifics are detailed by the state. You’ll want procedures in place to ensure the right protocols, procedures, forms, and documentation. Copays depend on the patient’s status. For example, emergency care and pregnancy services are exempt from copayment requirements for the medically needy. Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Claim Procedure (cont’d.) Prior Approval Durable medical equipment Hearing aids Hemodialysis Home health care Inpatient hospital care Long-term care facility services Medical supplies Medications Prosthetic or orthotic appliances Surgical procedures Transportation Vision care Prior approvals are necessary for many services, except an emergency. Describe some administrative processes that can help flag services requiring prior approval for this patient population. (send a prior authorization form, obtain an immediate authorization via telephone, send an authorization form to follow-up on telephone call) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Claim Procedure (cont’d.) Time limit Reciprocity Claim form Be aware of time limits for submitting the claim. These are set by the state. If you see out-of-state patients, most states have interstate agreements in place. Contact the Medicaid intermediary from the patient’s home state. What claim form is used by Medicaid? (CMS-1500 [08-05]) Describe the human services agency and the particulars of claims procedures in the students’ states. Explain how one might find these guidelines. (Answers will vary.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

After Claim Submission Remittance advice Appeals Remittance advice accompanies all Medicaid payment checks sent to the physician. Discuss some categories of adjudicated claims that are likely to appear. (adjustments, approvals, denials, suspends, audit/refund [A/R] transactions) Tell students the time limit for filing an appeal (generally). (varies by state, but usually 30-60 days) Explain where you can find detailed information about your state’s particular Medicaid policies and provisions. (Answers will vary.) Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.