Transcript Medicaid - Walla Walla Community College

Medicaid
OT 232
Chapter 11
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Medicaid
• Largest non-employer-sponsored health insurance program
• State administered and funded program that receives some
funds from federal government
– Federal funds are based on the state’s average per capita
income vs. the national average
• Established at the same time as Medicare, also under the
SS Act
– ….???....
– NINETEEN SIXTY-FIVE!!!
• Goal is to
– help eligible people with low income get comprehensive quality
healthcare AND
– administer it in the most efficient and economic way possible.
– See the problem? When these two don’t match, it’s the
healthcare providers or patients who come out short?
– Healthcare providers.
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Medicaid (cont’d.)
• To receive federal funds, states are required to
set up programs that meet minimum benefit
standards
– States can then determine what they want to
provide additionally
• Benefits AND eligibility vary from state to state
– A person may meet the minimum standards set by
the federal government, but not the additional
requirements of their state (to get additional
benefits).
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Federal Eligibility
• States must provide Medicaid to most individuals
who receive federally assisted income payments
– If someone needs help at the federal level, they need
it at the state level also.
• By meeting federal eligibility requirements, a
person is said to be ‘Categorically Needy’.
– See list on page 381
• Federal gov’t. also enacts legislations or
initiatives to expand Medicaid to other targeted
groups by agreeing to ‘match dollars’ on the
costs.
• These are not mandatory, just opportunities to
expand benefits at half the state’s cost
– Example, SCHIP, page 381
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Federal Eligibility (cont’d.)
• EPSDT
– Early and Periodic Screening, Diagnosis, and
Treatment
– Preventative care for eligible kids under 21
– Expansion of normal benefits to make sure kids
are screened for early detection and get
immunizations
– Some families with marginal incomes may have to
pay premiums
– Must cover all bullets on page 382, may cover
more
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Federal Eligibility (cont’d.)
• TWWHA
– Ticket to Work and Work Incentives Improvement
Act
– Makes Medicaid available at a reasonable
premium for workers with disabilities
– Created to address the problem of disabled
people not being able to work because their
income made them ineligible for Medicaid which
covers expensive disability care.
• Don’t have to choose between work and Medicaid.
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Federal Eligibility (cont’d.)
• New Freedom Initiative of 2001
– Partners federal and state agencies to support grants
to assist the elderly and disabled to ‘fully participate
in community life’
• Home and community based care
• Resource/activity centers
• Spousal Impoverishment Protection
– A Medicaid candidate cannot have much in the way of
assets, so this limits the amount of a couple’s income
and assets that must be used up before one of them is
eligible for Medicaid.
• So if one spouse needs long-term care, their assets are so
depleted that there’s not enough left for the healthy spouse
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Federal Eligibility (cont’d.)
• Welfare Reform Act of 1996
– Made aid more ‘temporary’
– AFDC became TANF
• Aid to Families with Dependent Children
• TEMPORARY Assistance for Needy Families
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–
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More stringent guidelines (again vary by state)
Eligibility determined by county
Some people are limited to a 5 year benefit period
Many states have employability or job search
requirements
– Eligibility is affected by bulleted questions on page 383
– Makes it more difficult for some groups to gain access to
Medicaid benefits
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State Programs
• States can exceed the level of benefits that must
be provided to the categorically needy
• Most states also provide Medicaid benefits to the
‘medically needy’
– Those who have high medical expenses and low
income
• They would not normally qualify for Medicaid except for
their high medical bills
– They are usually on a ‘spend down’ program (page
386)
• Like a deductible that resets every month
• They must reduce excess income to their state’s medically
needy income level
• Example in book
• This person’s annual income in how much too high?
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State Programs (cont’d.)
• Bullets at top of page 284 – Groups OFTEN
covered by state rules but not federal
– Note the common phrase “do not qualify under
federal rules, but who meet state income limit
rules”
• The state lets people qualify with a higher income level
than the minimum set by the federal gov’t.
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State Programs (cont’d.)
• Bullets at bottom list income and assets
guidelines for determining eligibility
– A person can work, but income must be lower than
the state’s set amount
– Not all income counts; some is excluded as needed for
necessary expenditure. Similar to taxes, there are
standard deductions of a certain amount.
– Not all assets are included in determining eligibility
(bank accounts and life insurance policies – yes,
furniture and clothing – no)
– A house can be included in assets when the person is
going into long-term care and leaving no one in the
house
– Transferred assets are examined for fraud
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Medicaid Enrollment Verification
• Time periods for Medicaid eligibility vary
greatly, so status must be verified every visit
(at least once a month)
– While checking eligibility, can also check for copay
or coinsurance
– ID cards are issued at various intervals by state
– If patient is on ‘restricted status’, they are required
to see a specific doctor who will be named on
their card. NO OTHER DOCTOR will be paid!
Patient is restricted due to some past abuse of
Medicaid.
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Medicaid Enrollment Verification
(cont’d.)
• Fraud and Abuse
– Since Medicaid is partially funded by federal
gov’t., they monitor for fraud and abuse.
– Since 2005, states can file their own fraud and
abuse suits and receive more compensation than
they would if the feds uncovered it.
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Covered & Excluded Services
• Covered Services
– First set of bullets on page 390 MUST be covered
by states to receive matching funds
– Federal matching funds are also provided for the
second set of bullets, which are services that
states are not required to provide.
– Cutbacks are leading to less additional eligibility
and coverage by states
• Excluded Services
– Vary by state, but bullets on page 390 are pretty
standard
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Types of Plans
• Most states offer both fee-for-service and
managed care plans
• Fee-for-Service
– Patient must use a provider who accepts Medicaid
• There is no ‘nonPAR’ since patients can’t afford to go
– Claims are submitted to Medicaid
– Medicaid usually pays a percentage of usual fee
• $90 usual fee, Medicaid pays 50% ($45). If there was a
$5 copay collected, Medicaid would pay $40.
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Types of Plans (cont’d.)
• Managed Care
– May become mandatory
– Typically control costs better so…
– Can offer increased services
– Structure is same – PCP, referrals, emphasis on
preventative, restriction to network
– Claims are sent to MCO (managed care
organization) rather than state’s Medicaid
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Payment for Service
• Providers must sign a contract with DHHS
before accepting Medicaid
• Providers must agree to conditions
– Accept everyone
– Accept Medicaid payment as payment in full
– Any difference in amounts must be written off
• STATES may require a copay
– Fixed – small fixed amount to help with admin
costs
– SOC (Share of Cost) – can change monthly
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Payment for Service(cont’d.)
• Patient can be billed for excluded services IF
– Patient was informed in advance, in writing, and
signed sheet saying they agreed
– AND the provider has an established written
policy for billing noncovered services that applies
to app patients (not just Medicaid).
• Physician cannot bill for
– Services performed without necessary
preauthorization
– Medically unnecessary services
– Claim filed past the time period for billing (usually
one year)
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Third Party Liability
• Payer of Last Resort
– Medicaid is ALWAYS billed last
– If other payers, usually won’t get much out of
Medicaid since the others will have probably paid
more than the Medicaid rate
• Medicare-Medicaid Crossover claims
– Called Medi-Medis (often elderly or disabled)
– Submit first to Medicare
– Medicaid will often pay Medicare deductibles,
coinsurance and/or premiums
• Kwimbees – Medicaid qualified, so state pays their Medicare
premiums, deductibles and coinsurance
• Slimbees – low income, but not Medicaid qualified, so state
pays their Medicare premiums only
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Claim Filing Guidelines
• Vary by state
• Washington – http://hrsa.dshs.wa.gov/
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