CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 11 Medicaid

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 11.1 Describe the purpose of the Medicaid program Discuss general eligibility requirements for Medicaid Explain the income and asset guidelines used by most states to determine eligibility Identify the procedures medical insurance specialists follow to verify Medicaid enrollment List the services that Medicaid usually does not cover. 11-2

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 11.6 State the types of plans that states offer Medicaid recipients Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage Demonstrate the ability to prepare correct Medicaid claims. 11-3

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms categorically needy crossover claim dual-eligible Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Federal Medicaid Assistance Percentage (FMAP) Medicaid Integrity Program (MIP) MediCal 11-4 medically needy Medi-Medi beneficiary payer of last resort restricted status spend-down State Children’s Health Insurance Program (SCHIP) Temporary Assistance for Needy Families (TANF) Welfare Reform Act

© 2012 The McGraw-Hill Companies, Inc. All rights reserved The Medicaid Program 11-5 Medicaid was established to pay for the health care needs of individuals and families with low incomes and few resources Federal Medicaid Assistance Percentage (FMAP)—basis for federal government Medicaid allocations to states

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Eligibility 11-6 Federal guidelines mandate coverage for individuals referred to as categorically needy— people who receive assistance from government programs Temporary Assistance for Needy Families (TANF)—program that provides cash assistance for low-income families

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Eligibility (Continued) 11-7 Medicaid coverage is available to: –People receiving TANF assistance –People eligible for TANF but not receiving assistance –People receiving foster care or adoption assistance under the Social Security Act –Children under six years of age from low-income families –Some people who lose cash assistance when their work income or Social Security benefits exceed allowable limits –Infants born to Medicaid-eligible pregnant women

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Eligibility (Continued) 11-8 Medicaid coverage is available to (continued): –People age sixty-five and over or legally blind or totally disabled people who receive Supplemental Security Income (SSI) –Certain low-income Medicare recipients The federal government requires the states to provide individuals in certain low-income or low- resource categories with Medicaid coverage

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Eligibility (Continued) 11-9 State Children’s Health Insurance Program (SCHIP)—offers health insurance coverage for uninsured children Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)—Medicaid’s prevention, early detection, and treatment program for eligible children under twenty-one Welfare Reform Act—law that established TANF and tightened Medicaid eligibility requirements

© 2012 The McGraw-Hill Companies, Inc. All rights reserved State Programs States establish their own eligibility standards When determining eligibility, states examine a person’s: –Income –Current assets (some assets are not counted) –Assets that have recently been transferred into another person’s name

© 2012 The McGraw-Hill Companies, Inc. All rights reserved State Programs (Continued) Medically needy—classification for people with high medical expenses and low financial resources MediCal—California’s Medicaid program Spend-down—state-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Medicaid Enrollment Verification Patients’ eligibility should be checked each time they make an appointment and before they see a physician –Patient’s Medicaid identification cards should be checked; in addition, a second form of identification is often checked Many states are developing the electronic verification of eligibility, in addition to telephone verification systems

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Medicaid Enrollment Verification (Continued) Restricted status—category of Medicaid beneficiary Medicaid Integrity Program (MIP)—created to prevent and reduce fraud, waste, and abuse in Medicaid

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Covered and Excluded Services States must cover certain services to receive federal matching funds –Some states also provide coverage for prescription drugs, dental or vision care, and other miscellaneous services Medicaid usually does not pay for: –Services that are not medically necessary –Procedures that are experimental or investigational –Cosmetic procedures

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Plans and Payments States offer a variety of plans, including fee-for- service and managed care plans –The trend is to shift recipients from fee-for-service plans to managed care plans A physician who wishes to provide services to Medicaid recipients must sign a contract with the Department of Health and Human Services (HHS)

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Third-Party Liability Before filing a claim with Medicaid, it is important to determine whether the patient has other insurance coverage –Other plan is billed first, then once the remittance advice from the primary carrier has been received, Medicaid may be billed Payer of last resort—regulation that Medicaid pays last on a claim

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Third-Party Liability (Continued) Medi-Medi beneficiary—person eligible for both Medicare and Medicaid –Dual-eligible—Medicare-Medicaid beneficiary Crossover claim—claim for a Medicare or Medicaid beneficiary

© 2012 The McGraw-Hill Companies, Inc. All rights reserved Claim Filing and Completion Guidelines Medical insurance specialists follow the general instructions for correct claims and also enter particular Medicaid data elements They need to know: –Where to file claims –Proper Medicaid coding methods –Unacceptable billing practices –Actions to take after filing a claim