Question

Medical Billing question:

1)Explain Medicaid eligibility guidelines

2) Describe how payments for Medicaid services are processed.

Answer 1

1. Medicaid was created by the Social Security Amendments of the year 1965, through which the Title XIX was added to the Social Security Act. It is a government insurance program for people of all ages who do not have sufficient resources and income to pay for their healthcare. The program covers around 23% of all Americans and is the largest source of public funds for health-related and medical services for people having low income in the country.

Eligibility for Medicaid

The Joint Federal-State Insurance program Medicaid provides nursing home/health coverage to certain low-income categories of people. Those covered include people with low assets like pregnant women, children, as well as the parents of eligible children. Elderly people who need nursing home care and people with disabilities are also covered by Medicaid. However while all the States of the country follow the same basic framework, there may be variations from one State to another in the eligibility rules. The eligibility conditions are categorical, which means that to get benefited under Medicaid the person should be a member of a category (as defined by the Statue).

Eligibility conditions have also been expanded under the Patient Protection and Affordable Care Act (PPACA). After this expansion, individuals were not required to undergo any resource/asset test, but their eligibility was now determined through an income tax test. It uses MAGI (Modified Adjusted Gross Income) criteria and is a standard income-based test. Therefore while the resource and asset tests were prohibited, the state-specific variations were also removed in the year 2019.

The income eligibility for Medicaid for most of the pregnant women, children, adults, and parents are now determined by MAGI, which considers the income and the tax filing scenarios for determining the finances and eligibility of any person for Medicaid. People over 65 years of age, the disabled, and the blind do not have to face the accounting rules of MAGI. For these individuals, the SSI program’s income methodologies (administered by the Social Security Administration) are used. Those enrolled in the cervical or breast cancer treatment program also need not undergo any determination procedure. Children who relate to the adoption assistant agreement (a Social Security Act provision) are also eligible automatically for Medicaid.

The non-financial eligibility conditions for Medicaid are that an individual should be a resident of the state, where he/she receives the insurance benefits. They may include certain categories of qualified non-citizens, including the lawful permanent residents, as well as the citizens of the United States of America.

2. Processing of payments for the Medicaid services

The managed care plan, the FFS (fee-for-service) model, or both of these procedures and methods may be used by the states to provide the benefits of Medicaid. In the FFS model, the state will make a direct payment to the health care service provider, which will cover each of the services that have been received by a beneficiary of Medicaid insurance. In the managed care model, the state will pay a fee for the managed care plan for all the people who are enrolled under it. After this, it will be the responsibility of the managed care plan to pay for the services that the providers have delivered to a beneficiary. These will be the services for which the plan will be in contract with the particular State.

The majority of all Medicaid enrollees, including adults (under age of 65 years), as well as the non-disabled children, fall under the category of managed care plans through which they avail their health insurance benefits. But the majority of spending or expenditures of Medicaid are for the FFS arrangement. Managed Care plans may have limited enrollment of the “high cost” benefit seekers and populations, including those with disabilities. These plans may also not cover certain important high-cost services including long-term healthcare services and nursing home services.

The Social Security Act, section 1902(a), 30 (A) requires that the payments made to the providers as fee for their service should be consistent with quality, economy, and efficiency of care. The Medicaid and Chip Payment and Access Commission (MACPAC) has a fully-documented list of services along with their fee, and these payments are specific for the States.