Understanding Medicaid

  1. What is Medicaid?: a combination of federal and state medical assistance program designed to provide comprehensive medical care for low income families
  2. Special emphasis: children, pregnant women, the elderly, the disabled, and parents with dependent children who have no other way to pay for healthcare
  3. Established: under Title 19 of the Social Security Act of 1965
  4. Federal government and state: share the cost; the state administers or runs the program
  5. State to state: benefits vary
  1. Evolution of Medicaid
  2. Original creation: to give low-income Americans access to healthcare
  3. Today: it’s a major social welfare program administered by CMS
  1. Structure of Medicaid
  2. Federal government’s role: established broad national guidelines; individually must fall into a designated group before they are eligible; see Fig 8-2
  3. State’s options: required to provide Medicaid coverage for certain people who receive federally assisted income-maintenance payments and for related groups snot receiving cash payments; must cover categorically need people, but have options on how they define it
  4. Categorically needy usually includes
  5. low income families with children
  6. individuals receiving SSI
  7. pregnant women, infants, and children with incomes less than a specified percent to the FPL (federal poverty level)
  8. qualified Medicare beneficiaries
  9. Mandated Services: to receive federal funds, states must offer these
  10. Inpatient and outpatient hospital services
  11. Physician services
  12. Medical and surgical dental services
  13. Nursing facility services for individuals age 21 or older
  14. Home healthcare for individuals eligible for nursing facility services
  15. Family planning services and supplies
  16. Rural health clinic services and any other ambulatory services offered by a rural health clinch that are otherwise covered under the stae plan
  17. Lab and x-ray services
  18. Pediatric and family nurse practitioner services
  19. Federally qualified health center services
  20. Nurse-midwife services
  21. Early and periodic screening, diagnosis, and treatment for individuals younger than 21
  22. optional services: state can provide as many or as few as they choose
  23. state children’s health insurance program (SCHIP): allows states to expand their Medicaid eligibility guidelines to cover more categories of children
  24. Fiscal Intermediaries: processes all healthcare claims on behalf of the Medicaid program
  1. Who Qualifies For Medicaid Coverage?
  2. Categorically needy: Figure 8-2
  3. Medically needy: may meet categorically needy category, but exceed income; must spend down or pay a share of their medical costs; coverage of their group is optional under federal law
  4. Program of All-Inclusive Care for the Elderly (PACE): provides comprehensive alternative care for noninstitutionalized elderly who otherwise would be in a nursing home
  5. Payment for Medicaid Services: paid directly to provider; provider must accept as payment in full
  6. Cost sharing: states can impose deductibles, copayments and coinsurance for some services with the exception of emergency care and family planning
  7. Certain people must be excluded from cost sharing: pregnant women, children younger than 18, hospital or nursing home patients, categorically needy HMO enrollees
  8. Medically necessary: Medicaid will only pay for services that are determined medically necessary; if you’re not sure if a procedure is medically necessary, check the Medicaid provider handbook or contact the fiscal intermediary; always do this before the procedure is performed to ensure payment
  9. Prescription drug coverage: all states cover prescription drugs for certain categorically needy patients
  10. Accepting Medicaid patients: provider has the right to accept or reject Medicaid patients; they can limit the number of Medicaid patients they accept as long as there isn’t any discrimination; if a patient has Medicare and Medicaid and the provider doesn’t accept Medicaid, the patient must know before the appointment
  11. Participating providers: must agree to accept what Medicaid pays as payment in full; if patient wants to be treated for a non-covered service, the patient must sign a waiver stating they are aware it is a non-covered service and they will be responsible
  1. Verifying Medicaid Eligibility
  2. When should this be done?: before every appointment
  3. Several methods
  4. Using patient ID card: check for dates on the card
  5. By phone—using touch tone or voice automated system
  6. Using Electronic Data Interchange (EDI): could be online database
  7. Point of Sale device: swipe card on credit card type machine
  8. Computer software program
  9. Benefits of Eligibility Verification System: reduces the number of denied claims, submission of more accurate claims; decreases eligibility related claims denial
  1. Medicare/Medicaid Relationship
  2. Dual coverage: receive Medicare coverage, but also receive Medicaid for some services
  3. Special Medicare/Medicaid Programs
  4. Qualified disabled and working individuals: lose Medicare benefits because they return to work. They are eligible to purchase Medicare hospital insurance
  5. Supplemental medical insurance: premiums not paid by Medicaid
  6. Specified low-income medicare beneficiaries: Medicaid will not pay for Medicare hospital insurance for this group
  7. Payer of last resort: all other available 3rd party resources must meet their legal obligation to pay claims before the Medicaid program pays for care of an individual eligible for Medicaid
  8. Medicare and Medicaid differences explained
  9. medicare isn’t tied to need: it’s an entitlement program because you pay taxes for it
  1. Medicaid claim
  2. Medicaid simple claim: Medicaid coverage only; no secondary insurance (Figure 8-4), (Figure 8-5) is for secondary
  3. Reciprocity: one state allows Medicaid beneficiaries from other states to be treated in its medical facilities (usually happens with neighboring states)
  1. Special Billing Notes
  2. Time Limit for Filing Medicaid claims: varies from state to state; always file ASAP
  3. Copayments: usually for podiatrist, dentists, and chiropractors; if you work for one of these doctors, you should check the Medicaid guidelines for your state
  4. Accepting assignment: block 27 on CMS-1500 must be checked yes or claim may be denied
  5. Preauthorization: for all hospitalization unless it was an emergency; in the case of emergency, most states require 24 hour notice; preauth # should be entered in block 23 of the CMS-1500
  6. Retention, Storage, and Disposal of Records
  7. HIPPA: 6 years
  8. Federal law: criminal or civil action can be taken in up to 7 years
  9. Privacy Act of 1974: kept indefinitely
  10. Can be kept on paper (least efficient), microfiche, CD-ROM or other storage devices
  1. Fraud and Abuse in the Medicaid System
  2. What is Medicaid fraud?: drives up costs; what are some examples
  3. Patient abuse and neglect: what are some indicator of abuse?