Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.

Slide 1
 Chapter 13
Medicaid and Other
State Programs

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 2
 Learning Objectives
 Benefits and nonbenefits of Medicaid.
 Define terminology related to Medicaid.
 Medicaid abbreviations.
 Name the two Medicaid eligibility
classifications.
 List important information to abstract
from the patient’s Medicaid card.
 Maternal and Child Health Program.

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 3
 Learning Objectives
(cont’d.)

 Eligibility for the Medicaid Qualified

Medicare Beneficiaries program.
 Basic operations of a Medicaid-managed
care system.
 Basic Medicaid claim guidelines.
 File claims for patients who have Medicaid
and other coverage.
 Minimize rejected insurance forms

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 4
 Chapter 13
Lesson 13.1

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 5
Medicaid (MCD) History
 Federal Emergency Relief
Administration – 1933-1935
 Social Security Act of 1935
 INCLUDED $ FOR MEDICAL COSTS
 PD TO RECIPIENTS

 1950—federal mandate to states

 States set up MEDICAID
 PD TO PROVIDERS

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 6
Medicaid (MCD) History

 1965 TITLE XIX BECAME

FEDERAL LAW
 Fiscal Responsibility Act
(TEFRA) – same benefits for
employees 65 & older

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 7
Medicaid (MCD) History

 Deficit Reduction Act (DEFRA) –

HAD TO SHOW PROOF OF
CITIZENSHIP AFTER 2006
 Child Health Assurance Program
(CHAP)
 State Children’s Health Insurance
program

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 8
 Maternal and Child
Health Program (MCHP)

 Provide low-income mothers and

children with quality care (200%
of the Federal Poverty level)
 Reduce infant mortality
 Increase child immunizations
 Pregnancy care

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 9
 Maternal and Child
Health Program (MCHP)
(cont’d.)

 Federal Grant $$$ - Title V of

the SS Act
 Preventive care
 Rehabilitation
 Special needs
 http://www.ncdhhs.gov/dma/med
icaid/index.htm
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 10
 Low-Income Medicare
Programs
MQMB (QMBs): The Medicaid
Qualified Medicare Beneficiary
program ( < FPL)
SLMB (SLMBs): The Specified
Low-Income Medicare Beneficiary
or SLMB (20% >FPL)
QIP: Qualifying individuals (135-
<175% OF FPL)
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 11
The 2011 Poverty Guidelines for the
48 Contiguous States and the District of Columbia

Persons in family Poverty guideline

1 $10,890
2 14,710
3 18,530
4 22,350
5 26,170
6 29,990
7 33,810
8 37,630
For families with more than 8 persons,
add $3,820 for each additional person.
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 12
Medicaid Eligibility
 NEEDY AND LOW INCOME
 ELDERLY
 BLIND/DISABLED
 FAMILIES W/DEPENDENT CHILDRENS
DEPRIVED OF SUPPORT
 US CITIZENS/ CERTAIN “QUALIFIED
IMMIGRANTS”

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 13
Medicaid Eligibility
 TWO BASIC CLASSIFICATIONS
 Categorically needy – TANF,
AFDC, SSI, QMB’S
(MANDATORY ELIGIBILITY)
 Medically needy (MN)– LOW
INCOME, MEDICALLY INDIGENT,
THOSE LOSING EMPLOYER
HEALTH INSURANCE
 (OPTIONAL ELIGIBILITY)
 (BOX 13.1 P. 456)
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 14
 Medicaid Eligibility
 Accepting Medicaid patients
(Provider signs a written provider
agreement to participate)
 Point-of-service machine – allows the
provider to check eligibility at time of
visit
 Retroactive eligibility – up to 90 days

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 15
Health Insurance Card

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 16
 Medicaid Eligibility
 EACH STATE DECIDES
WHICH additional SERVICES
ARE COVERED AND WHAT
THE PAYMENTS ARE FOR
EACH SERVICE
(see basic mandatory services– p.
460 box 13.2)

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 17
 Medicaid Benefits

 Covered services – specific

mandatory and optional services
and supplies that Medicaid
provides.
 Disallowed services – MD can
bill, but should have patient sign
a waiver of liability agreement.

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 18
 Claim Procedure

 Copayment – fixed or share of

cost (works like a deductible
each month)
 Prior approval – used for most
services except in an
emergency

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 19
Claim Procedure (cont’d.)
Services needing Prior Approval
 Durable medical  Medical supplies
equipment  Medications
 Hearing aids  Prosthetic or
 Hemodialysis orthotic
 Home health care appliances
 Inpatient hospital  Surgical
care procedures
 Transportation
 Long-term care
facility services  Vision care

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 20
Claim Procedure (cont’d.)

 Time limit to file a claim

 each state has its own limit (2-18
months)
 Reciprocity between states
 Claim form – CMS 1500 since
Oct 1 , 1986

Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 21
After Claim Submission

 Remittance advice – previously

known as the EOMB
 (see ex. On p. 465 Fig. 13-6)

 Appeals – pay attention to time

limits (30-60 days from the date
listed on the RA)
Copyright © 2008, 2006, 2004 by Saunders an imprint of Elsevier Inc. All rights reserved.
Slide 22