1. Insurance Handbook for the Medical Office
13th edition
Chapter 13
Medicaid and Other State Programs

2. Medicaid and Other State Programs
Lesson 13.1
Medicaid and Other State Programs
Define terminology relating to Medicaid.
Interpret Medicaid abbreviations.
Discuss the history of Medicaid.
Describe added benefits for Medicaid recipients afforded by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of

3. Medicaid and Other State Programs (cont’d)
Lesson 13.1
Medicaid and Other State Programs (cont’d)
Identify those eligible for the Medicaid Qualified Medicare Beneficiaries program.
Name the two Medicaid eligibility classifications.
State eligibility requirements and claims procedures for the Maternal and Child Health Program.
List important information to abstract from the patient’s Medicaid card.
Describe the Medicaid basic benefits.

4. Medicaid and Other State Programs (cont’d)
Lesson 13.1
Medicaid and Other State Programs (cont’d)
Explain basic operations of a Medicaid-managed care system.
Explain basic Medicaid claim procedure guidelines.
File claims for patients who have Medicaid and other coverage.
Interpret and post a remittance advice.
Describe filing an appeal for a Medicaid case.

5. 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
Review federal legislative activity leading to Medicaid.
Discuss state and federal coordination of assistance. (Medicaid is administered by state governments with partial federal funding; coverage varies by state, but the federal government sets minimum requirements.)
Discuss Medi-Cal (as appropriate).
Explain what federal law provides for a program of medical assistance for certain low-income individuals and families, and give the year it was enacted. (Title XIX of the Social Security Act – 1965.)
Discuss the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. (These Acts impact the Medicaid program by expanding access for childless adults, nonelderly, and non-pregnant individuals and include preventive services and long-term care benefits.)

6. Medicaid Programs Maternal and Child Health Program
Provide low-income mothers and children with quality care
Reduce infant mortality
Increase child immunizations
Pregnancy care
MCHP provides federal funds to states to enable them to:
Provide access to quality maternal and child health services.
Reduce the incidence of preventable diseases and handicapping conditions among children.
Increase the number of low-income children receiving health assessments and follow-up diagnostic and treatment services.
Provide prenatal, delivery, and postpartum care for low-income children.

7. Medicaid Programs Maternal and Child Health Program Preventive care
Rehabilitation
Special needs
MCHP provides federal funds to states to enable them to:
Provide preventive and primary care services for low-income children.
Provide rehabilitation services for the blind and disabled younger than 16 years of age.
Provide, promote, and develop family-centered, community-based, coordinated care for children with special healthcare needs.
What types of medical specialties most often service those patients in MCHP?

8. 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
QMBs (kwim-bees): Elderly and disabled below the poverty line. They pay Medicare Part B premiums, deductibles, and copays.
SLMB (slim-bee): Explain who is eligible for SLMB, what expenses are paid by the program, and what expenses are paid by the individual. (Elderly who are 20% above the federal poverty line; SLMB pays the Part B premium, and the patient pays Part B deductibles, copays, and noncovered items.)
QI: They may be 135% above the poverty line (but less than 175%). QI pays the premium.
Discuss what administrative system(s) could be used to ensure collection of the correct copays and deductibles from low-income Medicare patients. (Answers will vary.)

9. Medicaid Eligibility Categorically needy Medically needy
Maternal and Child Health Program eligibility
Spousal Impoverishment Protection Law
New Freedom Initiative
Explain who is eligible for Medicaid. (Elderly [65+], blind, disabled, members with dependent children with minimal support, low income/resources, U.S. citizen or “qualified immigrant”; See Box 13-1.)
Define “categorically needy.” (Aged, blind, or disabled individuals or families and children who meet financial eligibility requirements.)
Define “medically needy.” (Persons in need of financial assistance whose income and resources will not allow them to pay for the costs of medical care.)
Describe what steps should be taken to verify eligibility, and explain why verification is so important when accepting Medicaid patients. (See Box 13-1 for eligibility requirements.)

10. Accepting Medicaid Patients
Program participation
Identification care
Point-of-Service machine
Retroactive eligibility
Explain how a point-of-service machine works. (POS machine connects to state system to verify Medicaid coverage using information from a card.)
Define “retroactive eligibility,” and explain how it should be managed in the medical office. (A patient who receives medical care while applying for Medicaid should be treated as a cash patient; once Medicaid approves eligibility and sets a retroactive date for coverage, the patient should be reimbursed for any costs that will be billed to Medicaid.)

11. Identification Card Fig. 13-2
Become familiar with the Medicaid card that patients will present.
Explain why the card itself isn’t proof of eligibility. (State requirements, expiration dates, and changing conditions may affect eligibility and may not be reflected on the card.)
Explain how the information on the card (or patient registration form) should be used to verify eligibility. (Patient’s name, Medicaid ID number, gender, and date of birth should be used to confirm eligibility and submit claims to Medicaid.)

12. Medicaid Benefits Covered services Disallowed services
Early and periodic screening, diagnosis, and treatment
Disallowed services
Explain what types of services are covered under Medicaid and describe the types of medical practices and settings in which these services are performed. (See Box 13-2 for a list of covered services.)
Discuss what actions should be taken if a service is disallowed. (The physician can bill the patient in most states, if a service is disallowed by Medicaid.)

13. 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
Some states have adopted capitation (a flat fee per patient) rather than fee-for-service reimbursement.
In programs run for a number of years, it has been found that there is better access to primary health care and savings of monies in delivering the care if the programs are well managed.

14. Claim Procedures Copayment Prior approval Time limit Reciprocity
Some complexities are related to Medicaid claim procedures, and the specifics are detailed by the state. You’ll want procedures in place to ensure the right protocols, procedures, forms, and documentation.
Copays depend on the patient’s status. For example, emergency care and pregnancy services are exempt from copayment requirements for the medically needy.
Be aware of time limits for submitting the claim. These are set by the state.
If you see out-of-state patients, most states have interstate agreements in place. Contact the Medicaid intermediary from the patient’s home state.
Describe the human services agency and the particulars of claims procedures in the students’ states. Explain how one might find these guidelines. (Answers will vary.)

15. Claim Procedures Medicaid managed care
Maternal and Child Health Program
Medicaid and other plans
Government programs and Medicaid
Medicaid and immigrants
Chapter 7 includes general instructions for block-by-block entries on how to complete the CMS-1500 (02-12) claim form for the Medicaid program.
Because guidelines for completing the form vary among all Medicaid intermediaries, refer to the local Medicaid intermediary for their directions.

16. After Claim Submission
Remittance advice
Fig
Remittance advice accompanies all Medicaid payment checks sent to the physician.
Discuss some categories of adjudicated claims that are likely to appear. (Adjustments, approvals, denials, suspends, audit/refund [A/R] transactions)

17. 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
Explain where you can find detailed information about your state’s particular Medicaid policies and provisions. (Answers will vary.)

18. Questions?