CHAPTER 10

1. Medicaid CHAPTER 10

2. See the ten-step Revenue Cycle figure (at the beginning of the chapter). • This chapter focuses on the following step: • Preregister patients • Establish financial responsibility • Check in patients • Review coding compliance • Review billing compliance • Check out patients • Prepare and transmit claims • Monitor payer adjudication • Generate patient statements • Follow up payments and collections Chapter 10: Medicaid

3. When you finish this chapter, you should be able to: 10.1 Discuss the purpose of the Medicaid program. 10.2 Discuss general eligibility requirements for Medicaid. 10.3 Assess the income and asset guidelines used by most states to determine eligibility. 10.4 Evaluate the importance of verifying a patient’s Medicaid enrollment. 10.5 Explain the services that Medicaid usually does not cover. Learning Outcomes (1)

4. When you finish this chapter, you should be able to: 10.6 Describe the types of plans that states offer Medicaid recipients. 10.7 Discuss the claim-filing procedures when a Medicaid recipient has other insurance coverage. 10.8 Prepare accurate Medicaid claims. Learning Outcomes (2)

5. Key Terms • categorically needy • Children’s Health Insurance Program (CHIP) • crossover claim • dual-eligible • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) • Federal Medicaid Assistance Percentage (FMAP) • Medicaid Integrity Program (MIP) • MediCal • medically needy • Medi-Medi beneficiary • payer of last resort • restricted status • spenddown • Temporary Assistance for Needy Families (TANF) • Welfare Reform Act

6. Medicaid was established to pay for the healthcare needs of individuals and families with low incomes and few resources • Applicants must meet federal and state requirements • Federal Medicaid Assistance Percentage (FMAP)—basis for federal government Medicaid allocations to states • Based on state’s average per capita income in relation to national income averages 10.1 The Medicaid Program

7. Federal guidelines mandate coverage for any individual referred to as categorically needy—person who receives assistance from government programs (due to qualification through low income or resources) • Temporary Assistance for Needy Families (TANF)—program that provides cash assistance for low-income families 10.2 Eligibility (1)

8. 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 • People age sixty-five and over or legally blind or totally disabled people who receive Supplemental Security Income (SSI) • Certain low-income Medicare recipients 10.2 Eligibility (2)

9. Children’s Health Insurance Program (CHIP)—program that offers health insurance coverage for uninsured children (from low-income families whose incomes are not low enough to qualify for Medicaid) • Funded jointly by federal and state governments • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)—Medicaid’s prevention, early detection, and treatment program for eligible children under twenty-one • Well-child checkup—medical/dental health screening 10.2 Eligibility (3)

10. Ticket to Work and Work Incentives Improvement Act (TWWIIA) • Gives states the option of allowing individuals with disabilities to purchase Medicaid coverage that is necessary to enable them to maintain employment • New Freedom Initiative • Allows the elderly and people with disabilities to fully participate in community life • Promotes the use of at-home and community-based care as an alternative to nursing homes 10.2 Eligibility (4)

11. Spousal Impoverishment Protection • Limits the amount of a married couple’s income and assets that must be used before one of them can become eligible for Medicaid coverage in a long-term care facility (limiting the required “spenddown” to preserve the other spouse’s resources) • Welfare Reform Act—law that established TANF and tightened Medicaid eligibility requirements 10.2 Eligibility (5)

12. States establish their own: • Eligibility standards • Scope of services • Payments to providers • 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 10.3 State Programs (1)

13. Medically needy—classification of people with high medical expenses and low financial resources MediCal—California’s Medicaid program Spenddown—state-based Medicaid program requiring beneficiaries to pay part of their monthly medical expenses (until the patient’s income drops below the level specified by the state) 10.3 State Programs (2)

14. 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 to verify patient identity matches information on the card • Some states reissue Medicaid cards monthly (card is only good for one month) • Many states use an electronic verification of eligibility, in addition to telephone verification systems • Electronic Medicaid Eligibility Verification System (EMEVS) 10.4 Medicaid Enrollment Verification (1)

15. Restricted status—category of Medicaid beneficiary • Due to past abuse of Medicaid benefits • Limited to specific provider and pharmacy listed on the card • Medicaid Integrity Program (MIP)—program created to prevent and reduce fraud, waste, and abuse in Medicaid • http://www.cms.gov/MedicaidIntegrityProgram 10.4 Medicaid Enrollment Verification (2)

16. Covered Services • States must cover certain services to receive federal matching funds • Examples—inpatient and outpatient hospital services, physician services, and lab/x-ray services • Some states also provide coverage for prescription drugs, dental or vision care, and other miscellaneous services • Excluded Services • Medicaid usually does not pay for: • Services not medically necessary • Experimental or investigational procedures • Cosmetic procedures 10.5 Covered and Excluded Services

17. States offer a variety of plans, including fee-for-service and managed care plans • Fee-for-Service: Patient can see any provider that accepts Medicaid • Managed Care: Restricts patients to a network of specific providers • The trend is to shift recipients from fee-for-service plans to managed care plans • Payment for Services • A physician who wishes to provide services to Medicaid recipients must sign a contract with the Department of Health and Human Services (HHS) • Medicaid payment is considered payment in full 10.6 Plans and Payments

18. 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 • Medi-Medi beneficiary—person eligible for both Medicare and Medicaid • Dual-eligible—Medicare-Medicaid beneficiary • Payer of last resort—regulation that Medicaid pays last on a claim • Crossover claim—claim for a Medicare or Medicaid beneficiary 10.7 Third-Party Liability

19. 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 (fiscal intermediaries, Department of Health and Human Services, or the county welfare agency) • Proper Medicaid coding methods (CPT/HCPCS, ICD-10-CM guidelines) (continued) 10.8 Claim Filing and CompletionGuidelines (1)

20. They need to know (continued): • Unacceptable or fraudulent billing practices • 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 National Provider Identifier (NPI) when a physician working for or on behalf of a group practice or clinic performs services • Actions to take after filing a claim • Claims that are denied may be appealed within a certain time period, usually thirty to sixty days *end of presentation* 10.8 Claim Filing and CompletionGuidelines (2)