Medicaid

1. Medicaid OT 232 Chapter 11 OT 232 Ch 11 lecture 1

2. 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. OT 232 Ch 11 lecture 1

3. 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). OT 232 Ch 11 lecture 1

4. 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 OT 232 Ch 11 lecture 1

5. 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 OT 232 Ch 11 lecture 1

6. 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. OT 232 Ch 11 lecture 1

7. 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 OT 232 Ch 11 lecture 1

8. 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 • 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 OT 232 Ch 11 lecture 1

9. 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? OT 232 Ch 11 lecture 1

10. 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. OT 232 Ch 11 lecture 1

11. 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 OT 232 Ch 11 lecture 1

12. 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. OT 232 Ch 11 lecture 1

13. 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. OT 232 Ch 11 lecture 1

14. 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 OT 232 Ch 11 lecture 1

15. 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. OT 232 Ch 11 lecture 1

16. 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 OT 232 Ch 11 lecture 1

17. 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 OT 232 Ch 11 lecture 1

18. 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) OT 232 Ch 11 lecture 1

19. 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 OT 232 Ch 11 lecture 1

20. Claim Filing Guidelines • Vary by state • Washington – http://hrsa.dshs.wa.gov/ OT 232 Ch 11 lecture 1