Medicaid and Other State Programs Chapter 13 Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc.

2 Learning Objectives  Define terminology relating to Medicaid.  Interpret Medicaid abbreviations.  Discuss the history of Medicaid.  Identify those eligible for the Medicaid Qualified Medicare Beneficiaries program.  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.

3Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Learning Objectives (cont’d.)  List important information to abstract from the patient’s Medicaid card.  Explain basic operations of a Medicaid- managed care system.  Describe the Medicaid basic benefits.  Describe basic Medicaid claim procedure guidelines.  File claims for patients who have Medicaid and other coverage.

4Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Chapter 13 Lesson 13.1

5Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicaid (MCD) History  Federal Emergency Relief Administration  Social Security Act  1950—state programs  Deficit Reduction Act (DEFRA)  Fiscal Responsibility Act (TEFRA)  Medi-Cal

6Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Maternal and Child Health Program (MCHP)  Provide low-income mothers and children with quality care  Reduce infant mortality  Increase child immunizations  Pregnancy care

7Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Maternal and Child Health Program (MCHP) (cont’d.)  Preventive care  Rehabilitation  Special needs

8Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. 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

9Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicaid Eligibility  Categorically needy  Medically needy  Accepting Medicaid patients  Point-of-service machine  Retroactive eligibility

10Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Health Insurance Card

11Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Medicaid Benefits  Covered services  Disallowed services

12Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claim Procedure  Copayment  Prior approval

13Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claim Procedure (cont’d.)  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 Approval

14Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. Claim Procedure (cont’d.)  Time limit  Reciprocity  Claim form

15Elsevier items and derived items © 2010, 2008 by Saunders, an imprint of Elsevier Inc. After Claim Submission  Remittance advice  Appeals