Chapter 15

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Chapter 15

Medicaid


2

Introduction

• Medicaid helps in providing medical and health related services to families with limited resources or low income.


3

Under Broad Federal Guidelines

• States can:– Establish their own eligibility standards– Determine type, amount, duration, and

scope of services– Set rates of payment for services– Administer their own program


4

Medicaid Eligibility

• Medicaid is limited to individuals who fall into specified categories:– Pregnant women and resultant newborn

children– Children and teens up to ages 18 or 21– Depends on the state’s requirements


5


• Aged, blind, or disabled people who have low income

• Age 65 or older:– Terminally ill who want hospice – In a nursing facility and have low income– Aged, blind, or disabled and need a nursing

facility but can stay at home and get care


6


• Individuals eligible for Medicare and have low income and limited resources

• People who qualify for welfare

• Families with children under the age of 18

• People who cannot pay high medical bills


7

Special Groups States Must Assist

• Qualified Medicare beneficiaries

• Qualified working disabled individuals

• Qualifying individual

• Specified low-income Medicare beneficiary


8

State Children’s Health Insurance Program

• “The State Children’s Health Insurance Program was implemented in accordance with the balanced Budget act, which allows states to create or expand existing insurance programs and provides more federal funds to states for the purpose of expanding Medicaid eligibility to include a greater number of children who are currently uninsured.”


9

Mandatory Services

• Inpatient hospital services

• Outpatient hospital services

• Physician services

• Nursing facility services for individuals aged 21 and up


10

Mandatory Services

• Home health services for persons eligible for skilled nursing services

• Family planning services and supplies

• Prenatal care

• Rural health clinic services

• Laboratory and x-ray services


11

Mandatory Services

• Federally qualified health center and ambulatory services offered by and FQHC

• Early and periodic screening, diagnostic, and treatment services and immunizations for individuals under age 21


12

Additional Services

• Nursing facility care beyond the 100-day limit covered by Medicare

• Prescriptions drugs

• Eyeglasses

• Hearing aids


13

Medical Necessity

• Consistent with the recipient's symptoms, diagnosis, condition, or injury

• Recognized as the prevailing standard and consistent with generally accepted medical standards

• Provided in response to a life-threatening condition


14

Billing Notes

• Fiscal agent – Will vary from state to state

• Underwriter– Is shared between the state and federal

governments

• Form used– CMS-1500


15

Billing Notes

• Timely filing deadline– Check with your state’s Medicaid office

• It is important to file as soon as possible


16

Billing Notes

• Allowable determinations– Maximum reimbursement for each

nonmanaged care service

• Accept Assignment– Must be selected on the CMS-1500

• Deductibles– Are not always required


17

Billing Notes

• Copayments– Required for some Medicaid recipients

• Inpatient Benefits– Nonemergency must be preauthorized


18

Mother and Baby

• For the first 10 days of the infant’s life– Mother’s Medicaid identification number is

used

Chapter 15

Documents

Transcript of Chapter 15