Chapter 13 Medicaid and Other State Programs

1. Insurance Handbook for the Medical Office 13th edition Chapter 13 Medicaid and Other State Programs

2. Medicaid and Other State Programs Define terminology relating to Medicaid. Interpret Medicaid abbreviations. Discuss the history of Medicaid. Describe added benefits for Medicaid recipients afforded by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010. Lesson 13.1

3. Medicaid and Other State Programs (cont’d) Identify those eligible for the Medicaid Qualified Medicare Beneficiaries program. Name the two Medicaid eligibility classifications. State eligibility requirements and claims procedures for the Maternal and Child Health Program. List important information to abstract from the patient’s Medicaid card. Describe the Medicaid basic benefits. Lesson 13.1

4. Medicaid and Other State Programs (cont’d) Explain basic operations of a Medicaid-managed care system. Explain basic Medicaid claim procedure guidelines. File claims for patients who have Medicaid and other coverage. Interpret and post a remittance advice. Describe filing an appeal for a Medicaid case. Lesson 13.1

5. History • Federal Emergency Relief Administration • Social Security Act • 1950—state programs • Deficit Reduction Act (DEFRA) • Fiscal Responsibility Act (TEFRA) • Medi-Cal • Patient Protection and Affordable Care Act • Health Care and Education Reconciliation Act

6. Medicaid Programs • Maternal and Child Health Program • Provide low-income mothers and children with quality care • Reduce infant mortality • Increase child immunizations • Pregnancy care

7. Medicaid Programs • Maternal and Child Health Program • Preventive care • Rehabilitation • Special needs

8. Low-Income Medicare Recipients • MQMB (QMBs): The Medicaid Qualified Medicare Beneficiary program • SLMB (SLMBs): The Specified Low-Income Medicare Beneficiary or SLMB • QI: Qualifying individuals

9. Medicaid Eligibility • Categorically needy • Medically needy • Maternal and Child Health Program eligibility • Spousal Impoverishment Protection Law • New Freedom Initiative

10. Accepting Medicaid Patients • Program participation • Identification care • Point-of-Service machine • Retroactive eligibility

11. Identification Card

12. Medicaid Benefits • Covered services • Early and periodic screening, diagnosis, and treatment • Disallowed services

13. Medicaid Managed Care • States have brought managed care to Medicaid programs • Help control escalating health care costs • Curb unnecessary emergency department visits • Emphasize preventive care

14. Claim Procedures • Copayment • Prior approval • Time limit • Reciprocity

15. Claim Procedures • Medicaid managed care • Maternal and Child Health Program • Medicaid and other plans • Government programs and Medicaid • Medicaid and immigrants

16. After Claim Submission • Remittance advice

17. After Claim Submission • Appeals • Time limit to file varies state to state • Usually 30 to 90 days from date listed on RA • Pathway of appeal • Regional fiscal agent or Medicaid bureau • Department of Social Welfare or Human Services • Appellate court

18. Questions?