1. Slide 0 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

2. Slide 1 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Chapter 13 Medicaid and Other State Programs

3. Slide 2 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.

4. Slide 3 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.

5. Slide 4 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Chapter 13 Lesson 13.1

6. Slide 5 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

7. Slide 6 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

8. Slide 7 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

9. Slide 8 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

10. Slide 9 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

11. Slide 10 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Health Insurance Card

12. Slide 11 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Medicaid Benefits  Covered services  Disallowed services

13. Slide 12 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Claim Procedure  Copayment  Prior approval

14. Slide 13 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. 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

15. Slide 14 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. Claim Procedure (cont’d.)  Time limit  Reciprocity  Claim form

16. Slide 15 Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved. After Claim Submission  Remittance advice  Appeals