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Medicaid OT 232 Chapter 11 1OT 232 Ch 11 lecture 1.

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1 Medicaid OT 232 Chapter 11 1OT 232 Ch 11 lecture 1

2 Medicaid Largest non-employer-sponsored health insurance program State administered and funded program that receives some funds from federal government – Federal funds are based on the state’s average per capita income vs. the national average Established at the same time as Medicare, also under the SS Act – ….???.... – NINETEEN SIXTY-FIVE!!! Goal is to – help eligible people with low income get comprehensive quality healthcare AND – administer it in the most efficient and economic way possible. – See the problem? When these two don’t match, it’s the healthcare providers or patients who come out short? – Healthcare providers. 2OT 232 Ch 11 lecture 1

3 Medicaid (cont’d.) To receive federal funds, states are required to set up programs that meet minimum benefit standards – States can then determine what they want to provide additionally Benefits AND eligibility vary from state to state – A person may meet the minimum standards set by the federal government, but not the additional requirements of their state (to get additional benefits). 3OT 232 Ch 11 lecture 1

4 Federal Eligibility States must provide Medicaid to most individuals who receive federally assisted income payments – If someone needs help at the federal level, they need it at the state level also. By meeting federal eligibility requirements, a person is said to be ‘Categorically Needy’. – See list on page 381 Federal gov’t. also enacts legislations or initiatives to expand Medicaid to other targeted groups by agreeing to ‘match dollars’ on the costs. These are not mandatory, just opportunities to expand benefits at half the state’s cost – Example, SCHIP, page 381 OT 232 Ch 11 lecture 14

5 Federal Eligibility (cont’d.) EPSDT – Early and Periodic Screening, Diagnosis, and Treatment – Preventative care for eligible kids under 21 – Expansion of normal benefits to make sure kids are screened for early detection and get immunizations – Some families with marginal incomes may have to pay premiums – Must cover all bullets on page 382, may cover more OT 232 Ch 11 lecture 15

6 Federal Eligibility (cont’d.) TWWHA – Ticket to Work and Work Incentives Improvement Act – Makes Medicaid available at a reasonable premium for workers with disabilities – Created to address the problem of disabled people not being able to work because their income made them ineligible for Medicaid which covers expensive disability care. Don’t have to choose between work and Medicaid. OT 232 Ch 11 lecture 16

7 Federal Eligibility (cont’d.) New Freedom Initiative of 2001 – Partners federal and state agencies to support grants to assist the elderly and disabled to ‘fully participate in community life’ Home and community based care Resource/activity centers Spousal Impoverishment Protection – A Medicaid candidate cannot have much in the way of assets, so this limits the amount of a couple’s income and assets that must be used up before one of them is eligible for Medicaid. So if one spouse needs long-term care, their assets are so depleted that there’s not enough left for the healthy spouse OT 232 Ch 11 lecture 17

8 Federal Eligibility (cont’d.) Welfare Reform Act of 1996 – Made aid more ‘temporary’ – AFDC became TANF Aid to Families with Dependent Children TEMPORARY Assistance for Needy Families – More stringent guidelines (again vary by state) – Eligibility determined by county – Some people are limited to a 5 year benefit period – Many states have employability or job search requirements – Eligibility is affected by bulleted questions on page 383 – Makes it more difficult for some groups to gain access to Medicaid benefits OT 232 Ch 11 lecture 18

9 State Programs States can exceed the level of benefits that must be provided to the categorically needy Most states also provide Medicaid benefits to the ‘medically needy’ – Those who have high medical expenses and low income They would not normally qualify for Medicaid except for their high medical bills – They are usually on a ‘spend down’ program (page 386) Like a deductible that resets every month They must reduce excess income to their state’s medically needy income level Example in book This person’s annual income in how much too high? OT 232 Ch 11 lecture 19

10 State Programs (cont’d.) Bullets at top of page 284 – Groups OFTEN covered by state rules but not federal – Note the common phrase “do not qualify under federal rules, but who meet state income limit rules” The state lets people qualify with a higher income level than the minimum set by the federal gov’t. OT 232 Ch 11 lecture 110

11 State Programs (cont’d.) Bullets at bottom list income and assets guidelines for determining eligibility – A person can work, but income must be lower than the state’s set amount – Not all income counts; some is excluded as needed for necessary expenditure. Similar to taxes, there are standard deductions of a certain amount. – Not all assets are included in determining eligibility (bank accounts and life insurance policies – yes, furniture and clothing – no) – A house can be included in assets when the person is going into long-term care and leaving no one in the house – Transferred assets are examined for fraud OT 232 Ch 11 lecture 111

12 Medicaid Enrollment Verification Time periods for Medicaid eligibility vary greatly, so status must be verified every visit (at least once a month) – While checking eligibility, can also check for copay or coinsurance – ID cards are issued at various intervals by state – If patient is on ‘restricted status’, they are required to see a specific doctor who will be named on their card. NO OTHER DOCTOR will be paid! Patient is restricted due to some past abuse of Medicaid. OT 232 Ch 11 lecture 112

13 Medicaid Enrollment Verification (cont’d.) Fraud and Abuse – Since Medicaid is partially funded by federal gov’t., they monitor for fraud and abuse. – Since 2005, states can file their own fraud and abuse suits and receive more compensation than they would if the feds uncovered it. OT 232 Ch 11 lecture 113

14 Covered & Excluded Services Covered Services – First set of bullets on page 390 MUST be covered by states to receive matching funds – Federal matching funds are also provided for the second set of bullets, which are services that states are not required to provide. – Cutbacks are leading to less additional eligibility and coverage by states Excluded Services – Vary by state, but bullets on page 390 are pretty standard OT 232 Ch 11 lecture 114

15 Types of Plans Most states offer both fee-for-service and managed care plans Fee-for-Service – Patient must use a provider who accepts Medicaid There is no ‘nonPAR’ since patients can’t afford to go – Claims are submitted to Medicaid – Medicaid usually pays a percentage of usual fee $90 usual fee, Medicaid pays 50% ($45). If there was a $5 copay collected, Medicaid would pay $40. OT 232 Ch 11 lecture 115

16 Types of Plans (cont’d.) Managed Care – May become mandatory – Typically control costs better so… – Can offer increased services – Structure is same – PCP, referrals, emphasis on preventative, restriction to network – Claims are sent to MCO (managed care organization) rather than state’s Medicaid OT 232 Ch 11 lecture 116

17 Payment for Service Providers must sign a contract with DHHS before accepting Medicaid Providers must agree to conditions – Accept everyone – Accept Medicaid payment as payment in full – Any difference in amounts must be written off STATES may require a copay – Fixed – small fixed amount to help with admin costs – SOC (Share of Cost) – can change monthly OT 232 Ch 11 lecture 117

18 Payment for Service(cont’d.) Patient can be billed for excluded services IF – Patient was informed in advance, in writing, and signed sheet saying they agreed – AND the provider has an established written policy for billing noncovered services that applies to app patients (not just Medicaid). Physician cannot bill for – Services performed without necessary preauthorization – Medically unnecessary services – Claim filed past the time period for billing (usually one year) OT 232 Ch 11 lecture 118

19 Third Party Liability Payer of Last Resort – Medicaid is ALWAYS billed last – If other payers, usually won’t get much out of Medicaid since the others will have probably paid more than the Medicaid rate Medicare-Medicaid Crossover claims – Called Medi-Medis (often elderly or disabled) – Submit first to Medicare – Medicaid will often pay Medicare deductibles, coinsurance and/or premiums Kwimbees – Medicaid qualified, so state pays their Medicare premiums, deductibles and coinsurance Slimbees – low income, but not Medicaid qualified, so state pays their Medicare premiums only OT 232 Ch 11 lecture 119

20 Claim Filing Guidelines Vary by state Washington – OT 232 Ch 11 lecture 120


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