Chapter 15

1. 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. Medicaid Eligibility • 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. Medicaid Eligibility • 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