CHAPTER

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11Medicaid

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Learning Outcomes

When you finish this chapter, you will be able to:11.1 Describe the purpose of the Medicaid program.

11.2 Discuss general eligibility requirements for Medicaid.

11.3 Explain the income and asset guidelines used by most states to determine eligibility.

11.4 Identify the procedures medical insurance specialists follow to verify Medicaid enrollment.

11.5 List the services that Medicaid usually does not cover.

11-2

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Learning Outcomes (Continued)

When you finish this chapter, you will be able to:11.6 State the types of plans that states offer Medicaid

recipients.

11.7 Discuss the claim filing procedures when a Medicaid recipient has other insurance coverage.

11.8 Demonstrate the ability to prepare correct Medicaid claims.

11-3

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Key Terms

• categorically needy• crossover claim• dual-eligible• Early and Periodic

Screening, Diagnosis, and Treatment (EPSDT)

• Federal Medicaid Assistance Percentage (FMAP)

• Medicaid Integrity Program (MIP)

• MediCal

11-4

• medically needy

• Medi-Medi beneficiary

• payer of last resort

• restricted status

• spend-down

• State Children’s Health Insurance Program (SCHIP)

• Temporary Assistance for Needy Families (TANF)

• Welfare Reform Act

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11.1 The Medicaid Program 11-5

• Medicaid was established to pay for the health care needs of individuals and families with low incomes and few resources

• Federal Medicaid Assistance Percentage (FMAP)—basis for federal government Medicaid allocations to states

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11.2 Eligibility 11-6

• Federal guidelines mandate coverage for individuals referred to as categorically needy—people who receive assistance from government programs

• Temporary Assistance for Needy Families (TANF)—program that provides cash assistance for low-income families

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11.2 Eligibility (Continued) 11-7

• Medicaid coverage is available to:– People receiving TANF assistance– People eligible for TANF but not receiving assistance– People receiving foster care or adoption assistance

under the Social Security Act– Children under six years of age from low-income

families– Some people who lose cash assistance when their

work income or Social Security benefits exceed allowable limits

– Infants born to Medicaid-eligible pregnant women

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11.2 Eligibility (Continued) 11-8

• Medicaid coverage is available to (continued):– People age sixty-five and over or legally blind or

totally disabled people who receive Supplemental Security Income (SSI)

– Certain low-income Medicare recipients

• The federal government requires the states to provide individuals in certain low-income or low-resource categories with Medicaid coverage

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11.2 Eligibility (Continued) 11-9

• State Children’s Health Insurance Program (SCHIP)—offers health insurance coverage for uninsured children

• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)—Medicaid’s prevention, early detection, and treatment program for eligible children under twenty-one

• Welfare Reform Act—law that established TANF and tightened Medicaid eligibility requirements

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11.3 State Programs 11-10

• States establish their own eligibility standards• When determining eligibility, states examine a

person’s:– Income– Current assets (some assets are not counted)– Assets that have recently been transferred into

another person’s name

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11.3 State Programs (Continued) 11-11

• Medically needy—classification for people with high medical expenses and low financial resources

• MediCal—California’s Medicaid program• Spend-down—state-based Medicaid program

requiring beneficiaries to pay part of their monthly medical expenses

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11.4 Medicaid Enrollment Verification 11-12

• Patients’ eligibility should be checked each time they make an appointment and before they see a physician– Patient’s Medicaid identification cards should be

checked; in addition, a second form of identification is often checked

• Many states are developing the electronic verification of eligibility, in addition to telephone verification systems

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11.4 Medicaid Enrollment Verification (Continued)

11-13

• Restricted status—category of Medicaid beneficiary

• Medicaid Integrity Program (MIP)—created to prevent and reduce fraud, waste, and abuse in Medicaid

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11.5 Covered and Excluded Services 11-14

• States must cover certain services to receive federal matching funds– Some states also provide coverage for prescription

drugs, dental or vision care, and other miscellaneous services

• Medicaid usually does not pay for:– Services that are not medically necessary– Procedures that are experimental or investigational– Cosmetic procedures

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11.6 Plans and Payments 11-15

• States offer a variety of plans, including fee-for-service and managed care plans– The trend is to shift recipients from fee-for-service

plans to managed care plans

• A physician who wishes to provide services to Medicaid recipients must sign a contract with the Department of Health and Human Services (HHS)

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11.7 Third-Party Liability 11-16

• Before filing a claim with Medicaid, it is important to determine whether the patient has other insurance coverage– Other plan is billed first, then once the remittance

advice from the primary carrier has been received, Medicaid may be billed

• Payer of last resort—regulation that Medicaid pays last on a claim

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11.7 Third-Party Liability (Continued) 11-17

• Medi-Medi beneficiary—person eligible for both Medicare and Medicaid– Dual-eligible—Medicare-Medicaid beneficiary

• Crossover claim—claim for a Medicare or Medicaid beneficiary

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11.8 Claim Filing and CompletionGuidelines

11-18

• Medical insurance specialists follow the general instructions for correct claims and also enter particular Medicaid data elements

• They need to know:– Where to file claims– Proper Medicaid coding methods– Unacceptable billing practices– Actions to take after filing a claim