1. Medicaid and Other State Programs
Chapter 13
Medicaid and Other State Programs

2. Focus Medicaid basics Eligibility criteria Benefits
Managed Care coverage
Claim and after-claim procedures
Remittance Advice and Edit Correction Form
Website tour

3. Medicaid History Federal Emergency Relief Administration
Social Security Act
1950 – State Programs
Deficit Reduction Act (DEFRA)
Fiscal Responsibility Act (TEFRA)
Patient Protection and Affordable Care Act
Health Care and Education Reconciliation Act
Federal legislative activity leading up to current Medicaid program
Medicaid is administered by state governments with partial federal funding. Federal government sets minimum requirements, and states add their own requirements.
The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act expand Medicaid access for childless adults and non-pregnant women, includes preventive services and long-term care benefits.

4. Maternal and Child Health Program (MCHP)
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

5. Maternal and Child Health Program (MCHP) cont’d
Preventive care
Rehabilitation
Special Needs
MCHP also provides federal funds to
provide preventive and primary care for services for low-income children
provide rehabilitation services for the blind and disabled younger than 16 yo
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?

6. Low-Income Medicare Programs
MQMB (QMB): The Medicaid Qualified Medicare Beneficiary program
SLMB: The Specified Low-Income Medicare Beneficiary
QI: Qualifying Individual
Spousal Impoverishment Protection Law
New Freedom Initiative
QMBs (kwim-bees): Elderly and disabled below the poverty line. They pay Medicare Part B premiums, deductibles, and copays
SLMB (slim-bee) Elderly with income 20% above the poverty line; SLMB pays Parb B premium, patient pays Part B deductibles, copays, and noncovered items
QI: individuals with income 135% above but less than 175% the poverty line; QI pays the Part B premium

7. Medicaid Eligibility Categorically Needy Medically Needy
Accepting Medicaid patients
Verifying eligibility
Point-of-service machines
Internet verification
Retroactive eligibility
Who is eligible for Medicaid? Elderly over 65, blind, disabled, members with dependent children with minimal support, low income or resources, US citizen or a qualified immigrant
Categorically Needy – aged, blind, disabled individuals or families and children who meet financial eligibility requirements
Medically needy – in need of financial assistance show income and resources will not allow them to pay for the costs of medical care
Verifying eligibility
every visit
look for copay exemption, ambulatory visit limit, managed care organization status, other health insurance
make sure to have the patient’s name on file with Medicaid, date of birth, social security number, and Medicaid ID number
enrolled program – Family Planning Only, Emergency Services, Breast and Cervical Cancer Program
POS machine – like a credit card machine
Internet – Interactive WebTool
Retroactive eligibility
coverage may go back 90 days
a patient who receives medical care while applying for Medicaid should be treated as a cash patient
refund any monies paid if Medicaid covers past services

8. Health Insurance Card
Become familiar with the Medicaid card that patients present
Card does not guarantee eligibility
Medicaid ID card and Managed Care Organization ID card
Know what information is included on the card and what additional information will be needed from the patient
Eligibility not guaranteed
coverage runs from 1st to 30th or 31st of the month
patient can change plans or programs month to month
patient can terminate and renew month to month
Always get a copy of the MCO card in addition to the Medicaid ID card

9. Medicaid Benefits Eligibility categories Covered services
Disallowed services
See Box 13-2 for list of covered services
Coverage is dependent on the eligibility category
Physician can bill the patient in most states for disallowed services
have the patient sign a waiver

10. Claim Procedures Copayment Prior Approval
$3.30 for qualified ambulatory visit
Prior Approval
DME
Hearing aids
Hemodialysis
Home health care
IP hospital care
Long-term care facility services
Medical supplies
Prosthetic/Orthotic appliances
Surgical procedures
Transportation
Vision care
Copayment is dependent on the eligibility category
Some services may require prior approval
All inpatient admissions
Some outpatient procedures
Ultrasounds and advanced imaging
MCO requirements

11. Claim Procedures Time limit Reciprocity Claim form One year
Out of state
Claim form
CMS-1500
Timely filing limits are set by the state. SC is one year from date of service.
Reciprocity – filing an out-of-state Medicaid for services rendered
need an out-of-state agreement in place
no requirement to file out-of-state Medicaid plans
Claims must be filed electronically or direct data entry using the WebTool

12. Edit Correction Form Claim denials Red ink only
Attach missing documentation
File to PO Box 1412 Columbia SC
May or may not need a HC claim

13. Managed Care Organizations
First Choice Select Health
Blue Choice
Absolute Total Care
United Healthcare Community Plan of SC
Medical Home Networks

14. Managed Care Organizations, cont’d
Par / Non-par providers
Private, state, federal funding
Follow most of Medicaid’s directives
Separate guidelines, forms, billing, auth requirements
With few exceptions, all Medicaid beneficiaries must choose or be assigned to an MCO

15. Website Tour Provider Manual Fee Schedules
Bulletins and Press Releases

16. HOMEWORK Read Chapter 14 Tricare and ChampVA
Workbook Assignment: Review Questions, All Sections