11 Medicaid
Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>11.1  Describe the purpose ...
Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>11.6  State the...
Key Terms <ul><li>categorically needy </li></ul><ul><li>crossover claim </li></ul><ul><li>dual-eligible </li></ul><ul><li>...
11.1 The Medicaid Program <ul><li>Medicaid was established to pay for the health care needs of individuals and families wi...
11.2 Eligibility <ul><li>Federal guidelines mandate coverage for individuals referred to as  categorically needy— people w...
11.2 Eligibility (Continued) <ul><li>Medicaid coverage is available to: </li></ul><ul><ul><li>People receiving TANF assist...
11.2 Eligibility (Continued) <ul><li>Medicaid coverage is available to (continued): </li></ul><ul><ul><li>People age sixty...
11.2 Eligibility (Continued) <ul><li>State Children’s Health Insurance Program (SCHIP)— offers health insurance coverage f...
11.3 State Programs <ul><li>States establish their own eligibility standards </li></ul><ul><li>When determining eligibilit...
11.3 State Programs (Continued) <ul><li>Medically needy— classification for people with high medical expenses and low fina...
11.4 Medicaid Enrollment Verification <ul><li>Patients’ eligibility should be checked each time they make an appointment a...
11.4 Medicaid Enrollment Verification (Continued) <ul><li>Restricted status— category of Medicaid beneficiary </li></ul><u...
11.5 Covered and Excluded Services <ul><li>States must cover certain services to receive federal matching funds </li></ul>...
11.6 Plans and Payments <ul><li>States offer a variety of plans, including fee-for-service and managed care plans </li></u...
11.7 Third-Party Liability <ul><li>Before filing a claim with Medicaid, it is important to determine whether the patient h...
11.7 Third-Party Liability (Continued) <ul><li>Medi-Medi beneficiary— person eligible for both Medicare and Medicaid </li>...
11.8 Claim Filing and Completion Guidelines <ul><li>Medical insurance specialists follow the general instructions for corr...
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Survey of Medical Insurance pp ch11

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  • Teaching Notes:   Have students define all key terms as an assignment. Then, in class, ask each student to define one key term aloud.   Optional assignment: Have students do an Internet search of one key term and write a short paragraph describing what they learned about that term from looking at a few websites.
  • Learning Outcome: 11.1 Describe the purpose of the Medicaid program. Page: 430 Teaching Notes: Ask students to identify how people apply for Medicaid benefits. (People applying for Medicaid benefits must meet minimum federal requirements and any additional requirements of the state in which they live.)
  • Learning Outcome: 11.2 Discuss general eligibility requirements for Medicaid. Pages: 430-433 Teaching Notes:   Have students debate whether or not they think the eligibility requirements for Medicaid are too strict, too lenient, or appropriate.
  • Learning Outcome: 11.2 Discuss general eligibility requirements for Medicaid. Pages: 430-433 Teaching Notes:   Have students debate whether or not they think the eligibility requirements for Medicaid are too strict, too lenient, or appropriate.
  • Learning Outcome: 11.2 Discuss general eligibility requirements for Medicaid. Pages: 430-433 Teaching Notes:   Have students debate whether or not they think the eligibility requirements for Medicaid are too strict, too lenient, or appropriate.
  • Learning Outcome: 11.2 Discuss general eligibility requirements for Medicaid. Pages: 430-433 Teaching Notes:   Review the questions that people must answer for eligibility in the TANF program with your students. (See the bullet list of questions on page 433.)
  • Learning Outcome: 11.3 Explain the income and asset guidelines used by most states to determine eligibility. Pages: 433-437 Teaching Notes:   Ask your students why they think states establish their own eligibility standards.
  • Learning Outcome: 11.3 Explain the income and asset guidelines used by most states to determine eligibility. Pages: 433-437 Teaching Notes:   Have your students investigate their state Medicaid program, and discuss their findings in class.
  • Learning Outcome: 11.4 Identify the procedures medical insurance specialists follow to verify Medicaid enrollment. Pages: 437-440 Teaching Notes:   Ask your students why they think patients’ eligibility for Medicaid should be checked each time they make an appointment and before they see a physician.
  • Learning Outcome: 11.4 Identify the procedures medical insurance specialists follow to verify Medicaid enrollment. Pages: 437-440 Teaching Notes:   Have your students explain the restrictions that are placed on a Medicaid recipient who has a restricted status. (In restricted status, the patient is required to see a specific physician and/or use a specific pharmacy.)
  • Learning Outcome: 11.5 List the services that Medicaid usually does not cover. Pages: 440-441 Teaching Notes:   Ask your students to make a list of the services that the federal government requires states to cover. (See the bullet list on page 441.)
  • Learning Outcome: 11.6 State the types of plans that states offer Medicaid recipients. Pages: 442-443 Teaching Notes:   Have your students discuss the reason(s) they think the trend is to shift Medicaid recipients from fee-for-service plans to managed care plans.
  • Learning Outcome: 11.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage. Page: 444 Teaching Notes:   Have your students explain why they think Medicaid is the payer of last resort.
  • Learning Outcome: 11.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage. Page: 444 Teaching Notes:   Ask your students to name some reasons why they think the total amount paid by Medicare and Medicaid is subject to a maximum allowed limit.
  • Learning Outcome: 11.8 Demonstrate the ability to prepare correct Medicaid claims. Pages: 444-448 Teaching Notes:   Have your students list the unacceptable billing practices for physicians who contract with Medicaid. (Billing for services that are not medically necessary; billing for services not provided, or billing more than once for the same procedure; submitting claims for individual procedures that are part of a global procedure; submitting claims using an individual provider NPI when a physician working for or on behalf of a group practice or clinic performs services.)
  • Survey of Medical Insurance pp ch11

    1. 1. 11 Medicaid
    2. 2. Learning Outcomes <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>11.1 Describe the purpose of the Medicaid program. </li></ul><ul><li>11.2 Discuss general eligibility requirements for Medicaid. </li></ul><ul><li>11.3 Explain the income and asset guidelines used by most states to determine eligibility. </li></ul><ul><li>11.4 Identify the procedures medical insurance specialists follow to verify Medicaid enrollment. </li></ul><ul><li>11.5 List the services that Medicaid usually does not cover. </li></ul>11-2
    3. 3. Learning Outcomes (Continued) <ul><li>When you finish this chapter, you will be able to: </li></ul><ul><li>11.6 State the types of plans that states offer Medicaid recipients. </li></ul><ul><li>11.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage. </li></ul><ul><li>11.8 Demonstrate the ability to prepare correct Medicaid claims. </li></ul>11-3
    4. 4. Key Terms <ul><li>categorically needy </li></ul><ul><li>crossover claim </li></ul><ul><li>dual-eligible </li></ul><ul><li>Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) </li></ul><ul><li>Federal Medicaid Assistance Percentage (FMAP) </li></ul><ul><li>Medicaid Integrity Program (MIP) </li></ul><ul><li>MediCal </li></ul>11-4 <ul><li>medically needy </li></ul><ul><li>Medi-Medi beneficiary </li></ul><ul><li>payer of last resort </li></ul><ul><li>restricted status </li></ul><ul><li>spend-down </li></ul><ul><li>State Children’s Health Insurance Program (SCHIP) </li></ul><ul><li>Temporary Assistance for Needy Families (TANF) </li></ul><ul><li>Welfare Reform Act </li></ul>
    5. 5. 11.1 The Medicaid Program <ul><li>Medicaid was established to pay for the health care needs of individuals and families with low incomes and few resources </li></ul><ul><li>Federal Medicaid Assistance Percentage (FMAP)— basis for federal government Medicaid allocations to states </li></ul>11-5
    6. 6. 11.2 Eligibility <ul><li>Federal guidelines mandate coverage for individuals referred to as categorically needy— people who receive assistance from government programs </li></ul><ul><li>Temporary Assistance for Needy Families (TANF)— program that provides cash assistance for low-income families </li></ul>11-6
    7. 7. 11.2 Eligibility (Continued) <ul><li>Medicaid coverage is available to: </li></ul><ul><ul><li>People receiving TANF assistance </li></ul></ul><ul><ul><li>People eligible for TANF but not receiving assistance </li></ul></ul><ul><ul><li>People receiving foster care or adoption assistance under the Social Security Act </li></ul></ul><ul><ul><li>Children under six years of age from low-income families </li></ul></ul><ul><ul><li>Some people who lose cash assistance when their work income or Social Security benefits exceed allowable limits </li></ul></ul><ul><ul><li>Infants born to Medicaid-eligible pregnant women </li></ul></ul>11-7
    8. 8. 11.2 Eligibility (Continued) <ul><li>Medicaid coverage is available to (continued): </li></ul><ul><ul><li>People age sixty-five and over or legally blind or totally disabled people who receive Supplemental Security Income (SSI) </li></ul></ul><ul><ul><li>Certain low-income Medicare recipients </li></ul></ul><ul><li>The federal government requires the states to provide individuals in certain low-income or low-resource categories with Medicaid coverage </li></ul>11-8
    9. 9. 11.2 Eligibility (Continued) <ul><li>State Children’s Health Insurance Program (SCHIP)— offers health insurance coverage for uninsured children </li></ul><ul><li>Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) —Medicaid’s prevention, early detection, and treatment program for eligible children under twenty-one </li></ul><ul><li>Welfare Reform Act— law that established TANF and tightened Medicaid eligibility requirements </li></ul>11-9
    10. 10. 11.3 State Programs <ul><li>States establish their own eligibility standards </li></ul><ul><li>When determining eligibility, states examine a person’s: </li></ul><ul><ul><li>Income </li></ul></ul><ul><ul><li>Current assets (some assets are not counted) </li></ul></ul><ul><ul><li>Assets that have recently been transferred into another person’s name </li></ul></ul>11-10
    11. 11. 11.3 State Programs (Continued) <ul><li>Medically needy— classification for people with high medical expenses and low financial resources </li></ul><ul><li>MediCal— California’s Medicaid program </li></ul><ul><li>Spend-down— state-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses </li></ul>11-11
    12. 12. 11.4 Medicaid Enrollment Verification <ul><li>Patients’ eligibility should be checked each time they make an appointment and before they see a physician </li></ul><ul><ul><li>Patient’s Medicaid identification cards should be checked; in addition, a second form of identification is often checked </li></ul></ul><ul><li>Many states are developing the electronic verification of eligibility, in addition to telephone verification systems </li></ul>11-12
    13. 13. 11.4 Medicaid Enrollment Verification (Continued) <ul><li>Restricted status— category of Medicaid beneficiary </li></ul><ul><li>Medicaid Integrity Program (MIP)— created to prevent and reduce fraud, waste, and abuse in Medicaid </li></ul>11-13
    14. 14. 11.5 Covered and Excluded Services <ul><li>States must cover certain services to receive federal matching funds </li></ul><ul><ul><li>Some states also provide coverage for prescription drugs, dental or vision care, and other miscellaneous services </li></ul></ul><ul><li>Medicaid usually does not pay for: </li></ul><ul><ul><li>Services that are not medically necessary </li></ul></ul><ul><ul><li>Procedures that are experimental or investigational </li></ul></ul><ul><ul><li>Cosmetic procedures </li></ul></ul>11-14
    15. 15. 11.6 Plans and Payments <ul><li>States offer a variety of plans, including fee-for-service and managed care plans </li></ul><ul><ul><li>The trend is to shift recipients from fee-for-service plans to managed care plans </li></ul></ul><ul><li>A physician who wishes to provide services to Medicaid recipients must sign a contract with the Department of Health and Human Services (HHS) </li></ul>11-15
    16. 16. 11.7 Third-Party Liability <ul><li>Before filing a claim with Medicaid, it is important to determine whether the patient has other insurance coverage </li></ul><ul><ul><li>Other plan is billed first, then once the remittance advice from the primary carrier has been received, Medicaid may be billed </li></ul></ul><ul><li>Payer of last resort— regulation that Medicaid pays last on a claim </li></ul>11-16
    17. 17. 11.7 Third-Party Liability (Continued) <ul><li>Medi-Medi beneficiary— person eligible for both Medicare and Medicaid </li></ul><ul><ul><li>Dual-eligible— Medicare-Medicaid beneficiary </li></ul></ul><ul><li>Crossover claim— claim for a Medicare or Medicaid beneficiary </li></ul>11-17
    18. 18. 11.8 Claim Filing and Completion Guidelines <ul><li>Medical insurance specialists follow the general instructions for correct claims and also enter particular Medicaid data elements </li></ul><ul><li>They need to know: </li></ul><ul><ul><li>Where to file claims </li></ul></ul><ul><ul><li>Proper Medicaid coding methods </li></ul></ul><ul><ul><li>Unacceptable billing practices </li></ul></ul><ul><ul><li>Actions to take after filing a claim </li></ul></ul>11-18

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