Medicaid and Other State Programs Chapter 13 Medicaid and Other State Programs

Focus Medicaid basics Eligibility criteria Benefits Managed Care coverage Claim and after-claim procedures Remittance Advice and Edit Correction Form Website tour

Medicaid History Federal Emergency Relief Administration Social Security Act 1950 – State Programs Deficit Reduction Act (DEFRA) Fiscal Responsibility Act (TEFRA) Patient Protection and Affordable Care Act Health Care and Education Reconciliation Act Federal legislative activity leading up to current Medicaid program Medicaid is administered by state governments with partial federal funding. Federal government sets minimum requirements, and states add their own requirements. The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act expand Medicaid access for childless adults and non-pregnant women, includes preventive services and long-term care benefits.

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

Maternal and Child Health Program (MCHP) cont’d Preventive care Rehabilitation Special Needs MCHP also provides federal funds to provide preventive and primary care for services for low-income children provide rehabilitation services for the blind and disabled younger than 16 yo provide, promote, and develop family-centered, community-based, coordinated care for children with special healthcare needs What types of medical specialties most often service those patients in MCHP?

Low-Income Medicare Programs MQMB (QMB): The Medicaid Qualified Medicare Beneficiary program SLMB: The Specified Low-Income Medicare Beneficiary QI: Qualifying Individual Spousal Impoverishment Protection Law New Freedom Initiative QMBs (kwim-bees): Elderly and disabled below the poverty line. They pay Medicare Part B premiums, deductibles, and copays SLMB (slim-bee) Elderly with income 20% above the poverty line; SLMB pays Parb B premium, patient pays Part B deductibles, copays, and noncovered items QI: individuals with income 135% above but less than 175% the poverty line; QI pays the Part B premium

Medicaid Eligibility Categorically Needy Medically Needy Accepting Medicaid patients Verifying eligibility Point-of-service machines Internet verification Retroactive eligibility Who is eligible for Medicaid? Elderly over 65, blind, disabled, members with dependent children with minimal support, low income or resources, US citizen or a qualified immigrant Categorically Needy – aged, blind, disabled individuals or families and children who meet financial eligibility requirements Medically needy – in need of financial assistance show income and resources will not allow them to pay for the costs of medical care Verifying eligibility every visit look for copay exemption, ambulatory visit limit, managed care organization status, other health insurance make sure to have the patient’s name on file with Medicaid, date of birth, social security number, and Medicaid ID number enrolled program – Family Planning Only, Emergency Services, Breast and Cervical Cancer Program POS machine – like a credit card machine Internet – Interactive WebTool Retroactive eligibility coverage may go back 90 days a patient who receives medical care while applying for Medicaid should be treated as a cash patient refund any monies paid if Medicaid covers past services

Health Insurance Card Become familiar with the Medicaid card that patients present Card does not guarantee eligibility Medicaid ID card and Managed Care Organization ID card Know what information is included on the card and what additional information will be needed from the patient Eligibility not guaranteed coverage runs from 1st to 30th or 31st of the month patient can change plans or programs month to month patient can terminate and renew month to month Always get a copy of the MCO card in addition to the Medicaid ID card

Medicaid Benefits Eligibility categories Covered services Disallowed services See Box 13-2 for list of covered services Coverage is dependent on the eligibility category Physician can bill the patient in most states for disallowed services have the patient sign a waiver

Claim Procedures Copayment Prior Approval $3.30 for qualified ambulatory visit Prior Approval DME Hearing aids Hemodialysis Home health care IP hospital care Long-term care facility services Medical supplies Prosthetic/Orthotic appliances Surgical procedures Transportation Vision care Copayment is dependent on the eligibility category Some services may require prior approval All inpatient admissions Some outpatient procedures Ultrasounds and advanced imaging MCO requirements

Claim Procedures Time limit Reciprocity Claim form One year Out of state Claim form CMS-1500 Timely filing limits are set by the state. SC is one year from date of service. Reciprocity – filing an out-of-state Medicaid for services rendered need an out-of-state agreement in place no requirement to file out-of-state Medicaid plans Claims must be filed electronically or direct data entry using the WebTool

Edit Correction Form Claim denials Red ink only Attach missing documentation File to PO Box 1412 Columbia SC May or may not need a HC claim

Managed Care Organizations First Choice Select Health Blue Choice Absolute Total Care United Healthcare Community Plan of SC Medical Home Networks

Managed Care Organizations, cont’d Par / Non-par providers Private, state, federal funding Follow most of Medicaid’s directives Separate guidelines, forms, billing, auth requirements With few exceptions, all Medicaid beneficiaries must choose or be assigned to an MCO

Website Tour Provider Manual Fee Schedules Bulletins and Press Releases

HOMEWORK Read Chapter 14 Tricare and ChampVA Workbook Assignment: 14-1 Review Questions, All Sections