Chapter 13 Medicaid and Other State Programs

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

13th edition

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


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


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


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


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


Medicaid Programs

Maternal and Child Health Program Preventive care Rehabilitation Special needs

7


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


Medicaid Eligibility

Categorically needy Medically needy Maternal and Child Health Program

eligibility Spousal Impoverishment Protection Law New Freedom Initiative

9


Accepting Medicaid Patients

Program participation Identification care Point-of-Service machine Retroactive eligibility

10


Identification Card

11


Medicaid Benefits

Covered services Early and periodic screening, diagnosis, and

treatment Disallowed services

12


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


Claim Procedures

Copayment Prior approval Time limit Reciprocity

14


Claim Procedures

Medicaid managed care Maternal and Child Health Program Medicaid and other plans Government programs and Medicaid Medicaid and immigrants

15


After Claim Submission

Remittance advice

16


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


Questions?

18

Documents

Chapter 13 Medicaid and Other State Programs