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44 Cards in this Set
- Front
- Back
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What is medicaid?
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State and federally funded health care program for certain low income and medically vulnerable persons
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Is medicaid state or federally run?
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Each state operates its own distinct program under the oversight of the federal govt
To be eligible for federal funds, states are req'd to provide Medicaid coverage for most indiv's who receive Federally assisted income maintenenace payments, as well as related groups not receiving cash payments |
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Do the states have any discretion in determining which groups their medicaid will cover?
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They have some but there are many "mandatory Medicaid eligibility groups" that the federal govt requires to be eligiblefor federal funds
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What is AFDC? Title? What is the significance for medicaid?
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Aid ot famillies with dependent children - section 1931 of SSA
Federally assisted incomes to families with children (if below certain income) States must extend medicaid coverage to this group to be eligible for federal funds |
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Relationship between SSI and medicaid?
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One of the madatory eligibility groups states must extend Medicaid to to be eligible for federal funds
In states with more restrictive criteria -- aged, blind and disabled ppl who meet crieria approved for State's Medicaid plan as of Jan 1972 |
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Wat is the mandatory elibility group description for infants born to Medicaid-eligible pregnant women?
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Medicaid eligibility must continue t/o the first year of life so long as teh infant remains in the mother's household and she remains eligible, or would be eligible if she were still prego
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What is the minimum mandatory income level for pregnant women and infants that the federal govt requires states to extend medicaid eligibility to?
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Usually 133% of the Federal Poverty Level
May be higher in certain states if the state established this by a certain date This is extended to children under 6 and pregnant women whose family income is at or below this 133% level |
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When are states required to extend Medicaid elibility to children up to 19 yo?
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Children born after Sept 1983 i families with income at or below the Federal Poverty Line
This phases in coverage so that by 2002, all poor children will be covered |
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Once established, how long do pregnant women remain eligible for Medicaid?
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Thru the end of the calendar month in which the 60th day after the end of pregnancy falls
Regardless of any change in family income |
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Are states req'd to have a resource test for the poverty level related groups?
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No. But, any resource test imposed can be no more restrictive than AFDC program for infants and the SSI program for prego women
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Examples of mandatory Medicaid elgibility groups imposed by the federal govt?
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Low income families with kids (AFDC)
SSI recipients Infants born to medicaid-eligible women Children under 6 and prego women whose family income is < 133% poverty level All children <19 with family incomes at or < than poverty level REcipients of adoption assistance and foster care (Title IV-E SSA) Certain Medicar beneficiaries Special protected groups |
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Exaples of special protected groups who are one of the mandatory medicaid eligibility groups
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Persons who lose SSI due to earnings rom work or inc SS benefits
Families who are provided 6 to 12 months of Medicaid coverage following loss of eligibility uner section 1931 due to earnings, or 4 months of Medicaid cverage following loss of eligibility under section 1931 due to an inc in child or spousal support |
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What are "optional groups" that the state may choose to extend Medicaid to? Why would they do this?
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Categorically needy groups that share charcteristics of the mandatory groups, but the eligibility criteria is more "liberal"
Do it b/c federal goverment will match it |
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Examples of optional groups the state may cover as categorically needy?
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Infants up to age 1 and prego women with income at or below 185% poverty limit
Optional targeted low income kids Certain aged, blind, disabled adults who have incomes above those requiring mandatory coverage, but below Federal poverty limit Children under 21 who meet income andresources req's for AFDC Institutionalized indiv's w/ income/resources below specified limits Recipients of State supplementary payents TB-infected ppl Low income, uninsured women with breast or cervical cancer |
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Who administers Medicaid in Ohio?
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Ohio Department of Job and Family Services (ODJFS) thru 88 county dept. of job and family services
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What programs does Meidcaid cover in Ohio?
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Helathy Start
Healthy Families Medicaid for aged, blind, and disabled |
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3 General eligibility req's for Ohio Medicaid
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1. US citizen or meet Medicaid citizenship req's
2. Ohio resident 3. Meet certain financial req's |
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Who does Ohio provide Medicaid to?
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Children up to 19
Prego women Families with children under 18 Adults 65 and older Legally blind Disabled |
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9 GENERAL things Ohio Medicaid covers
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Prescription drugs
Hospital stay Home health care Long term care Hospice Care Oupt services Mental Health services DME Transportation |
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How many prescription drugs are coverd under Ohio Medicaid? Copay?
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25,000
$3.00 copay May need prior auth when a drug is prescribed and a less costly alternative is available |
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Examples of when drugs don't require a copay under Ohio Medicaid?
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Birth control, condoms, family planning services
If given in a hospital, ER, clinic, or office If for someone under 21, prgo, in a nursing home or intermediate care for mental retarded Receiving hospice care Enrolled in a MCP |
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When does Medicaid cover hospital stays?
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When medically necessary
Surgery and anesthesia (pre-cert) |
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What part of pregnancy services does medicaid pay for?
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EVERYTHING - they really encourage poor people to breed
Pre and post-natal visits, childbirth classes, labor and delivery, hospital stay, US's and well-baby care |
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What does Medicaid pay for for Home Health Care?
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part time daily living care in the home
Nursing and skilled therapies when medically necessary |
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What type of long term care does medicaid pay for?
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Nursing home
Intermediate Care Facility for the Mentally Retarded |
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When will medicaid pay for hospice?
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life expectancy less than 6 months
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What outpatient services does medicaid cover?
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Physician visits (24 in a year)
Lab testing/x-rays Prostate, pelvic exams, mammograms ST, OT, PT Hearing, eye, dental shit Dermatology ER Prevention: booster, flu, pneumonia vaccines |
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How many PT services does medicaid authorize in a year?
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30
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When does medicaid cover OT services?
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Hospital only
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What board does medicaid cover mental health services?
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Alcohol, Drug addiction and mental health board
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Does medicaid cover DME?
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Yes, but need prior auth
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What Health Check Screening does Ohio offer?
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Ohio's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) for babies, children, teens, young adults
birth, 1, 2, 4, 6, 12, 15, 18, 24 months and every year there after |
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What does Ohio's Early Periodic Screening, Diagnosis, and Treatment (EPSDT) cover?
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Complete physical exam
Lead testing Vision, dental, hearing checks Nutrition assessment Immunizations Mental health services Tests for sickle cell, STDs, addiction Counseling and education |
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Examples of shit not covered by medicaid?
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Not medically necessary
Experimental services Certain organ transplants Abortions Infertility services Tx of obesity Custodial/supportive care Sex or marriage counseling Paternity testing |
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What is spenddown?
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For aged, blind, diabled whose income is too high. They subtract medicaid income level from their income level, and thats how much they have to spenddown
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3 ways a person can be eligible for medicaid with spenddown?
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1. Person can pay in each month with a check to DJFS
2. Incur medical coss that equal the spend down for the month (medical bills, ins permiums, copays, deductibles, medicare premiums, transportation costs for medical care) 3. Can use the bills of a spouse, parent, sister, or brother to help meet spend down |
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Does medicaid require copays or coinsurance?
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Nope. Only copay is on prescription drugs
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Explain the transfer of assests provisions
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States withhold payment for long term care or home/commuity-based waiver services when pt (or spouse) disposes of assets for less than fair market value
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How far can states "look back" to determine transfer of assets?
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36 months prior to date of institutionalization or when applies for medicaid
May extend to 60 months for certain trusts |
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Penalty period
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Period of time state will withhold payment for nursing facility
Determined by dividing the value of the transferred asset by the average montly private-pay rate for nursing facility in the state |
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Exceptions for when a penalty period will not apply
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Transfers to a spouse, or third party for the benefit of the spouse
Transfers to disabled indiv's, or to trusts established for those indiv's Transfers for purpose other than to qualify for Medicaid Transferwhen imposing a penalty would cause undue hardship |
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3 types of MCO offered under medicaid
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Molina - no preauth
Unisson - no preauth if gold star Care Source - no preauth |
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Which type of MCO medicaid has gold star members?
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Unisson. If physician is a gold star member than no preauth req'd
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Brachialis
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Elbow: Flexion
Innervation: Musculocutaneous (C5, C6) |
