1. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved 1 Chapter 13 Medicaid and Other State Programs Insurance Handbook for the Medical Office 13 th edition

2. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid and Other State Programs 1. Define terminology relating to Medicaid. 2. Interpret Medicaid abbreviations. 3. Discuss the history of Medicaid. 4. Describe added benefits for Medicaid recipients afforded by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. 2 Lesson 13.1

3. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid and Other State Programs (cont’d) 5. Identify those eligible for the Medicaid Qualified Medicare Beneficiaries program. 6. Name the two Medicaid eligibility classifications. 7. State eligibility requirements and claims procedures for the Maternal and Child Health Program. 8. List important information to abstract from the patient’s Medicaid card. 9. Describe the Medicaid basic benefits. 3 Lesson 13.1

4. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid and Other State Programs (cont’d) 10. Explain basic operations of a Medicaid-managed care system. 11. Explain basic Medicaid claim procedure guidelines. 12. File claims for patients who have Medicaid and other coverage. 13. Interpret and post a remittance advice. 14. Describe filing an appeal for a Medicaid case. 4 Lesson 13.1

5. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved History  Federal Emergency Relief Administration  Social Security Act  1950—state programs  Deficit Reduction Act (DEFRA)  Fiscal Responsibility Act (TEFRA)  Medi-Cal  Patient Protection and Affordable Care Act  Health Care and Education Reconciliation Act 5

6. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid Programs  Maternal and Child Health Program  Provide low-income mothers and children with quality care  Reduce infant mortality  Increase child immunizations  Pregnancy care 6

7. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid Programs  Maternal and Child Health Program  Preventive care  Rehabilitation  Special needs 7

8. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Low-Income Medicare Recipients  MQMB (QMBs): The Medicaid Qualified Medicare Beneficiary program  SLMB (SLMBs): The Specified Low-Income Medicare Beneficiary or SLMB  QI: Qualifying individuals 8

9. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid Eligibility  Categorically needy  Medically needy  Maternal and Child Health Program eligibility  Spousal Impoverishment Protection Law  New Freedom Initiative 9

10. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Accepting Medicaid Patients  Program participation  Identification care  Point-of-Service machine  Retroactive eligibility 10

11. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Identification Card 11

12. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid Benefits  Covered services  Early and periodic screening, diagnosis, and treatment  Disallowed services 12

13. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Medicaid Managed Care  States have brought managed care to Medicaid programs  Help control escalating health care costs  Curb unnecessary emergency department visits  Emphasize preventive care 13

14. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Procedures  Copayment  Prior approval  Time limit  Reciprocity 14

15. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Claim Procedures  Medicaid managed care  Maternal and Child Health Program  Medicaid and other plans  Government programs and Medicaid  Medicaid and immigrants 15

16. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved After Claim Submission  Remittance advice 16

17. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved After Claim Submission  Appeals  Time limit to file varies state to state Usually 30 to 90 days from date listed on RA  Pathway of appeal Regional fiscal agent or Medicaid bureau Department of Social Welfare or Human Services Appellate court 17

18. Copyright ©2014 by Saunders, an imprint of Elsevier Inc. All rights reserved Questions? 18