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Chapter 10 Medicaid What Is It? Federal assistance program—not insurance—for medical care Coverage depends on each state Who Qualifies? Categorically needy Low income with few resources Families with dependent children eligible for Social Security Income Pregnant women with low income, children o Medically needy High medical expenses, low financial resources, but not low enough for cash assistance Aged, blind, disabled—low income higher than poverty level Children meeting TANF limits Pregnant women not meeting other federal qualifications, but who meet state income limits Programs Qualifying for Medicaid CHIP (children’s health insurance program) low income, but not low enough to be “needy” funded jointly by state and federal governments EPSDT (early, periodic screening, diagnosis, and treatment) For people under 21 enrolled in Medicaid Preventive care and immunizations Physicals Vision, hearing, dental Periodic screenings Ticket to Work and Work Incentives Improvement Act Incentive program for people on SSI to return to work “Go to work and lose your medical benefits” New Freedom Initiative Governments working with states to help people with disabilities to participate in communities. Prevent “locking away” theory Grant money provided for programs Spousal Impoverishment Protection (Joint Resources) Limits how much of a couple’s resources have to be used up before they can qualify for Medicaid Often one is in a nursing facility or medical institution Welfare Reform Act TANF (Temporary Assistance for Needy Families) Income and resources are below limits Household has at least one child under 18 At least one parent is not present, unemployed, or incapacitated Must have SSN and birth certificate May receive adoptive or foster care assistance TANF qualifications determined by county State Programs Federal government sets broad standards, but Medicaid is run by the state States establish their own eligibility standards Federal funding depends on programs offered by each state Medically Needy High medical expenses, low financial resources Each state decides who is covered Aged, blind, disabled Institutionalized or who would be but are being cared for at home Under 21 on TANF Infants and pregnant women not qualifying for federal State supplementary recipients People with TB financially eligible for Medicaid Uninsured women needing breast or cervical cancer tx People Qualifying for Medically Needy: May have a reasonable income from employment Assets taken into account for eligibility not homes being lived in by recipient Not clothing, furniture, personal effects or money put aside for burial Spenddown Recipient pays medical bills until their level of assets reach certain level determined by the state Monthly spenddown Recipient pays certain amount toward medical expenses each month—similar to a monthly deductible Enrollment Verification Check patient eligibility each visit Medicaid Eligibility Verification System (electronic) Each patient should have an active card Often patients have to show alternate form of ID Medicaid Integrity Program Prevent and reduce fraud, waste, and abuse False Claims Act (aka Lincoln Law) Whistleblowing against people defrauding the government States can enact their own act, but will not receive federal matching rates for Medicaid What’s Covered? To receive federal funding, must provide Inpt and outpt hospital Physician, lab, x-ray Transportation to medical care ESPDT for those who qualify Skilled nursing, home healthcare Free standing birth centers, midwife services, family planning and supplies Pediatric Some states also provide Vision, hearing, dental Prosthetics Prescription drugs Rehab Dx services Cutbacks effect what is offered, to whom it is offered, payments to doctors What is Not Included Not medically necessary services Clinical Trials Experimental or investigative Cosmetic procedures Medicaid Payments Fee-for-service—pt sees any Medicaid approved provider. Provider accepts assignment. Claims sent to Medicaid contractor. Managed Care—pt sees network provider, PCP monitors care. Claims sent to managed care organization Payment for Service—similar to FFS but providers CAN bill the patient for services not covered Medicaid Patient Payments No premiums No deductibles No coinsurance Small copays Possibly noncovered services if Patient is informed (ABN) Providers in capitation plans still bill Medicaid for reporting purposes Provider May Not Bill For Services requiring preauthorization that are denied by Medicaid Services not medically necessary Services not paid because of delay in sending claim Third-party Liability Medicaid is “payer of last resort” Billing Priorities 1. 2. 3. 4. 5. Liability Group Self subscriber Medicare or Tricare/CHAMPVA Medicaid Medi-Medi Plans Dual Eligible Crossover Claims Medicare adjudicates the claim first, then Medicaid adjudicates Who would qualify for a Medi-Medi claim? Filing Claims Send to state-appointed contractor Primarily send electronically (HIPAA 837P) Medi-Medi claims are sent once Medicaid denied claims can be appealed through state’s contractor
