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35 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
Each state operates its own distinct program under the oversight of the Federal govt--uses federal monies |
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Which Title of the SS act is Medicaid and when was it passed
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Title 19
1965 |
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What do states have to do to be eligible for federal funds
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Provide Medicaid coverage for most individuals who receive Federally assisted income maintenance payments--as well as for related groups not receiving cash payments
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Give some examples of mandatory Medicaid eligibility groups
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1. Low income families with children who meet certain eligibility requirements in the state's Aid to Families with Dependant Children (AFDC)
2. Supplemental Social Security (SSI) recipients 3. Infants born to Medicaid-eligible pregnant women--Medicaid eligibility must continue throughout the 1st year of life so long as the infant remains in the mother's household and she remains eligible 4. Children under age 6 and pregnant women whose family income is at or below 133% of the Federal poverty level 5. Medicaid eligibility extends until the age of 19 to all children born after September 30, 1983 in families with incomes at or below the Federal poverty level 6. Recipients of adoption assistance and foster care under Title IV-E of the SSA 7.Certain Medicare Beneficiaries 8. Special protected groups who may keep Medicaid for a period of time -Persons who lose SSI benefits d/t earnings from work or increased SS benefits -Families are provided 6-12 months of Medicaid coverage after loss of eligibility d/t earnings -Families also get 4 months of Medicaid coverage following the loss of eligibility d/t and increase in child or spousal support |
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How long do pregnant women remain eligible for Medicaid?
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Once eligibility is established, pregnant women remain eligible through the end of the calender month in which the 60th day after the end of the pregnancy falls--regardless of any change in family income
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Describe the groups that state's have the option of extending Medicaid benefits too?
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"Categorically Needy" Groups:
1. Infants up to age 1 and pregnant women not covered under the mandatory rules whose family income is below 185 percent of the Federal poverty level (Each state sets a specific %) 2. Optional targeted low income children 3. Certain aged, blind, or disabled adults who have incomes above those requiring mandatory coverage--but below the Federal poverty level 4. Children under 21 who meet income and resources requirements for AFDC, but who otherwise are not eligible for AFDC 5. Institutionalized individuals with income and resources below specified limits 6. Persons who would be eligible if institutionalized but are receiving care under home and community-based services waivers 7. Recipients of State supplementary payments 8. TB-infected persons who would be financially eligible for Medicaid at the SSI level (only for TB-related ambulatory services and drugs) 9. Low income, uninsured women screened and dx through a Center's for Disease Control and Prevention's Breast and Cervical Cancer Early Detection Program and determined to be in need of treatment for breast of cervical cancer |
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What organizations administer Medicaid in Ohio
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Ohio Department of Job and Family Services (ODJFS)--one in each county
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What 3 things do you need to be eligible for Medicaid
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1. US citizen or meet Medicaid citizenship requirements
2. Be an Ohio Resident 3. Meet certain financial requirements |
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Who does Medicaid provide coverage too? These people have to meet the financial requirements
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1. Children (up to the age of 19)
2. Pregnant women 3. Families with children under age 18 4. Adults 65 and older 5. Persons who are legally blind 6. Persons with disabilities |
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What things does Medicaid cover?
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1. Prescription Drugs
2. Hospital Stay 3. HHC 4. LTC 5. Hospice Care 6. Outpt Services 7. Mental health services 8. DME 9. Transportation services |
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How many prescription drugs does Medicaid cover
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Over $25,000
Prior authorization may be needed when a drug is prescribed and a less costly alternative is available |
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What is a typical co-payment for prescription drugs
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$3
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When is there no co-payment for prescription drugs
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If they are for:
1. Birth control, condoms, family planning services 2. Given in a hospital, ER, clinic or office 3. For someone under the age of 21, pregnant, in a nursing home or intermediate care facility, or mentally retarded, receiving hospice care, or enrolled in an MCP |
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What things may require pre-certification in hospital stays
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Surgery & anesthesia
Medicaid pays for all pregnancy related services--child birth classes, labor/delivery, ultrasounds, pre & postnatal visits Hospital stays are covered if deemed medicallynecessary |
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What does Medicaid cover with HHC
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Part time daily living care in the home (helps with more than just healthcare--prevention purpose to decrease long term costs)
Nursing and skilled therapies are available when medically necessary |
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What types of pts are covered under Medicaid in nursing homes and LTC facilities
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Mentally Retarded
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When does medicare pay for nursing home stays
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If pt is staying in a "Skilled Bed"
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When does Medicaid cover pts in Hospice care
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When life expectancy if 6 months or less
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What types of things does Medicaid cover under outpt services
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1. Up 24 physician visits per yr
2. Lab testing and X-rays 3. Family planning 4. Prostate exams (once every 12 months in pts over 50); pap smears & pelvic exams (once every 12 months in pts over 16); mammography (once every 12 months over 40) 5. ST if medically necessary 6. PT--30 visits per yr 7. OT covered in hospital only 8. Hearing services for adults and children 9. Dental check-ups and cleaning every 6 months 10. Regular eye exams (every 24 months if 21-59); Every 12 months if over or under this age grouping--includes one pair of glasses for the same time period if needed in each age category 11. Dermatology services 12. ER services 13. Prevention: tetanus booster (every 10 yrs); flu shot; pneumonia shot (over 65) |
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What Dental care does Medicaid cover but require prior authorization
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Extractions and fillings
Braces and Dentures |
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What visual care does Medicaid cover but require pre authorization
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Contacts, prosthetic eye, low vision aids
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What organization does Medicaid go through for Mental Health Services
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Alcohol, Drug Addiction, and Mental Health board (ADAMH)
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Does DME require pre authorization
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Yes
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What is EPSDT
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Ohio's Early Periodic Screening, Diagnosis, and Treatment for babies, children, teens, & young adults
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When she kids be scheduled for a health check screen through EPSDT
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Birth
1 month 2 months 4 months 6 months 12 15 18 24 |
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What all is included in the EPSDT Health Check Screenings covered under Medicaid
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1. Complete physical exam
2. Lead testing 3. Vision, dental, and hearing checks 4. Nutrition assessment 5. Immunizations 6. Mental Health services 7. Tests for sickle cell anemia, STDs, alcohol and drug addiction 8. Counseling and education |
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What are the services not covered under Medicaid
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1. Services and supplies not medically necessary
2. Experimental services and procedures 3. Certain organ transplants 4. Abortions except in the case of rape or incest or when necessary to save the mother's life 5. Infertility services 6. Reversal of voluntary sterilization procedures 7. Treatment of obesity 8. Custodial or supportive care 9. Sex change surgery 10. Sexual or marriage counseling 11. Acupuncture or biofeedback 12. Paternity testing |
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How is Medicaid used for people of 65 that already have Medicare
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Medicaid acts as their way of paying the extra 20% of co-payment that they would normally pay and Medicare acts as their insurance
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Who is a "Spenddown" program for ?
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All who are aged, blind, or disabled but their income is too high
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How does the Spenddown program work
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Persons can "pay in" each months with a check to local DJFS
Can incur costs for medical services that equal the spend down for the month -Medical bills (physician visits, dental, ect -Medical INS premiums -Medical INS co-pays and deductibles -Medicare premiums -Transportation costs for medical care Pts can alsl use the bills of a spouse, parent, sister, or brother to help meet spend down Essentially the person pays money in because they are slightly over the income level--by paying money in they become eligible for Medicaid with a lower income--more total money |
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What if a patient has Medicaid and private insurance
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Other insurance must be used before Medicaid
-There is no payment for co-pays or co-insurance except for prescription drugs ($3 co-pay) -If pt has a Managed Care Plan (MCP) they maybe eligible for other services |
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Describe the Transfer of Assets Provision
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States must withhold payment for various long term care services for individuals who dispose of assets for less than fair market value
Assets includes both resources and income These provisions apply when assets are transferred bu individuals in LTC facilities or receiving home and community-based waiver services, or by their spouses, or someone else acting on their behalf States can look back to find transfer of assets for 36 months prior to the date the individual is institutionalized -For certain trusts this look back period extends 60 months |
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If a transfer of assets for less than fair market value is found what will the State do?
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State must withhold payment for nursing facility care for a period of time referred to as the penalty period
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How is the length of the penalty period determined
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Dividing the value of the transferred asset bu the average monthly private-pay rate for nursing facility care in the state
-A $90,000 transferred asset divided by a $3,000 avg monthly private pay rate--would result in a 30 month penalty period -There is no limit to the length the penalty period can be |
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What types of transfers are exceptions from the transfer of assets rule?
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1. Transfers to a spouse, or a 3rd party for the sole benefit of the spouse
2. Transfers by a spouse to a 3rd party for the sole benefit of the spouse 3. Transfers to certain disabled individuals, or to trusts established for those individuals 4. Transfers for a purpose other than to qualify for Medicaid 5. Transfers where imposing a penalty would cause undue hardship |
