Medicaid

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Medicaid

• Payor of Last Resort

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What is it?

• Federal AND State program
• Established in 1965 under Title XIX of the Social
  Security Act
• Federal government makes payments to states based
  on

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Average Per Capita Income

• North Carolina per capita income
• Richmond County per capita income
• National per capita income

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So...

• Since per capita incomes vary from state to
  state.so do the payments that the federal
  government makes. This means that coverage is not
  reciprocal!

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How to Apply

• Go to DSS (Department of Social Services)
• Take proof of assets, income, etc.
• Takes 45-60 days to process

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Categorically Needy

• The FEDERAL government mandates that each state
  care for its categorically needed people.
• Categorically needy means cannot afford the
  basics, health, food, clothes, shelter

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CHIP

• Childrens Health Insurance Program
• Part of Medicaid, established in 1997 out of the
  Balanced Budget Act

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CHIP

• Goal is to assist states in providing coverage
  for uninsured or underinsured children.
• The state develops the program and the federal
  government matches the funds that the state
  invests in the program for .

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EPSDT

• Early Periodic Screening, Diagnosis Treatment
• For Medicaid children under age 21.

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Emphasis of EPSDT

• Prevention, prevention, prevention
• Medical, hearing, vision, dental

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Medically Needy

• The STATE (not FEDERAL) government opts to
  provide for its medically needy people.
• Medically needy can afford housing, food,
  clothes, just not medical.

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Medically Needy

• Do not meet federal cash assistance eligibility
  requirements.
• High medical expenses and low financial resources

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Spend Down

• Sort of like a Medicaid deductible
• Clients must spend a portion of their paycheck
  (on their health care)in order to be at or below
  a certain income level.
• The spend down resets every month.

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For example

• A patient has a 100.00 spend down and goes to
  the MD on July 3rd.
• The bill is 75.00
• The patient has to pay the entire 75.00.
• Later in July she goes back to the MD and is
  charged 60.00. She has to pay 25.00
  (7525100) and Medicaid pays the rest. Next
  month, it starts over.

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Eligibility

• Check your patients card EVERY month for the
  eligibility dates. You also need to know if they
  have a copayment or not.
• Restricted status Some patients may have
  restricted Medicaid. They have to see a certain
  MD and use a certain pharmacy. This MD will be
  named on the card. If it isnt your employer, you
  cant see the pt.

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Covered vs. Not Covered

• Inpatient hospital
• Outpatient hospital
• MD services
• ER services
• Lab and xray
• Prenatal care
• EPSDT
• SNF over 21

• Home health over 21
• Vaccinations

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Not covered

• If it isnt Medically Necessarynot covered
• If it is experimental.not covered
• If it is cosmetic..not covered

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Types of Plans

• Fee-for-service
• Managed care (Carolina Access)

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The Doctor says Sign me UP!

• Has to sign a contract with the Department of
  Health and Human Services.
• Agree not to discriminate
• Accept Medicaid payment as payment in full

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And...

• Cannot bill the patient for additional amounts
  over what Medicaid says is UCR
• Must write off the difference
• Patient can be billed for coinsurance,
  deductibles or copayments

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ButThe patient can be billed if

• They were told BEFORE the procedure that it
  wasnt covered
• The MD has a written policy for billing uncovered
  services that applies to everyone..not just
  Medicaid pts.
• The patient is told ahead of time and agrees, in
  writing, to pay the charge.

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Denials (if denied for any of thesetoo bad)

• Didnt obtain a preauthorization number.
• Service was not medically necessary.
• Claim was not filed on time (one year after date
  of service)

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Payor of Last Resort

• I cant think of an instance when, if the patient
  has dual coverage, Medicaid would be bill first.
  Soconsider it ALWAYS the Payor of Last Resort.