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Special Groups
States are required to assist the following
special groups:
Qualified Medicare beneficiaries (QMB) (states
pay Medicare premiums, deductibles and
coinsurance amounts for individuals whose
income is at or below100 percent of the federal
poverty level and whose resources are at or
below twice the standard allowed under SSI)
Special Groups
States are required to assist
the following special groups:
Qualified working disabled
individuals (QWDI) (states pay
Medicare Part a premiums for
certain disabled individuals
who lose Medicare coverage
because of work; these
individuals have incomes
below 200 percent of the
federal poverty level and
resources that are no more
than twice the standard
allowed under SSI)
Special Groups
States are required to assist the
following special groups:
Qualifying individual (QI) (states pay
Medicare Part B premiums for
individuals with incomes between
120 percent and 175 percent of the
federal poverty level)
Specified low-income
Medicare beneficiary (SLMB)
(states pay Medicare Part B
premiums for individuals with
incomes between 100 percent
and 120 percent of the
federal poverty level)
Special Groups
States may also improve access to
employment, training, and
placement of people with
disabilities who want to work by
providing expanded Medicaid
eligibility to:
Working disabled people between ages
16 and 65 who have income and
resources greater than that allowed
under the SSI program.
Working individuals who become
ineligible for the group described above
because their medical conditions
improve. (states may require these
individuals to share in the cost of their
medical care.)
Special Groups
Two additional eligibility groups are related to
specific medical conditions, and states may
provide coverage under their Medicaid plans:
Time-limited eligibility for women who have breast
or cervical cancer
Individuals diagnosed with tuberculosis (TB) who
are uninsured.
Spousal Impoverishment
Protection
To determine whether the spouse
residing in a facility meets the
states resource standard for
Medicaid, a protected resource
amount (PRA) is subtracted from
the couples combined resources.
The PRA is the greatest of the:
Spousal share, up to a maximum of
$109,560 in 2011.
State spousal resource standard,
which a state could set at any amount
Mandatory Services
To receive federal matching funds, states must
offer the following services:
Services for Categorically Needy Eligibility
Groups
Services for Medically Needy Eligibility
Groups
Preauthorized Services
Preauthorized Services
Most states that have not placed all
Medicaid beneficiaries into a
prepaid HMO have some form of
prior approval or preauthorization
for recipients.
Preauthorization guidelines include:
Elective inpatient admission
Emergency inpatient admission
More than one preoperative day
(document reason[s] surgery cannot be
performed within 24 hours of indication
for surgery and specify number of
additional preoperative day[s]
requested)
Preauthorized Services
Preauthorization guidelines include:
Outpatient procedure(s) to be performed in an
inpatient setting (submit CPT code and description of
surgical procedure along with medical necessity
justification for performing surgery on an inpatient
basis)
Days exceeding state hospital stay limitation due to
complication(s) (submit diagnosis stated on original
preauthorization request, beginning and ending dates
originally preauthorized, statement describing the
complication[s], date complication[s] presented,
principal diagnosis, and complication[s] diagnosis)
Extension of inpatient days (document medical
necessity justification for the extension and specify
number of additional days requested)
Medicare-Medicaid Relationship
Medicare beneficiaries with low
incomes and limited resources may
also receive help from the Medicaid
program
For those eligible for full Medicaid
coverage, Medicare coverage is
supplemented by services available
under a states Medicaid program.
Additional services may include
Nursing facility care beyond the 100day limit covered by Medicare
Prescription drugs
Eyeglasses
Hearing aids.
Participating Providers
Any provider who accepts a Medicaid patient
must accept the Medicaid determined payment
as payment in full.
Providers are forbidden by law to bill patients
for Medicaid-covered benefits.
A patient may be billed for any service that is
not a covered benefit; however, some states
have historically required providers to sign
formal participating Medicaid contracts.
Other states do not require contracts.
Preauthorization guidelines
include:
Elective inpatient admission
Emergency inpatient admission
More than one preoperative
day
Outpatient procedure(s) to be
performed in an inpatient
setting
Days exceeding state hospital
stay limitation due to
complication(s)
Extension of inpatient days
Utilization Review
The federal government requires states
to verify the receipt of Medicaid services.
A sample of Medicaid recipients is sent a
monthly survey letter requesting
verification of services paid the previous
month on their behalf.
Federal regulations also required
Medicaid to establish and maintain a
surveillance and utilization review
subsystem (SURS), which safeguards
against unnecessary or inappropriate use
of Medicaid services or excess payments
and assesses the quality of those
services.
Utilization Review
A post payment review process monitors both the
use of health services by recipients and the delivery
of health services by providers.
Overpayments to providers may be recovered by the
SURS unit, regardless of whether the payment error
was caused by the provider or by the Medicaid
program.
The SURS unit is also responsible for identifying
possible fraud or abuse, and most states organize
the unit under the states Office of Attorney General,
which is certified by the federal government to
detect, investigate, and prosecute fraudulent
practices or abuse against the Medicaid program.
Medical Necessity
Medicaid-covered services are payable only when the
service is determined by the provider to be medically
necessary. Covered services must be:
Consistent with the patients symptoms, diagnosis,
condition, or injury.
Recognized as the prevailing standard and consistent
with generally accepted professional medical standards
of the providers peer group.
Provided in response to a life-threatening condition; to
treat pain, injury, illness, or infection; to treat a
condition that could result in physical or mental
disability; or to achieve a level of physical or mental
function consistent with prevailing community
standards for diagnosis or condition.
Medical Necessity
In addition, medically necessary services are:
Not furnished primarily for the convenience of the
recipient or the provider.
Furnished when there is no other equally effective
course of treatment available or suitable for the
recipient requesting the service that is more
conservative or substantially less costly.
Fiscal Agent
The name of the states Medicaid fiscal agent
will vary from state to state.
Underwriter
Underwriting responsibility is shared between
state and federal governments.
Federal responsibility rests with CMS. The
name of the state agency will vary according
to state preference.
Form Used
The CMS-1500 claim is required.
Allowable Determination
The state establishes the maximum
reimbursement payable for each non
managed care service.
It is expected that Medicaid programs will
use the new Medicare physician fee
schedule for these services, with each state
establishing its own conversion factor.
Medicaid recipients can be billed for any
noncovered procedure performed. However,
because most Medicaid patients have
incomes below the poverty level, collection
of fees for uncovered services is difficult.
Accept Assignment
Accept assignment must be selected on the CMS-1500
claim, or reimbursement may be denied.
It is illegal to attempt collection of the difference
between the Medicaid payment and the fee the
provider charged, even if the patient did not reveal
Medicaid status at the time services were rendered.
Deductibles
A deductible may be required. In such cases, eligibility
cards usually are not issued until after the stated
deductible has been met.
Copayments
Copayments are required for some Medicaid recipients.
Inpatient Benefits
All nonemergency hospitalizations must be
preauthorized.
If the patients condition warrants an extension of
the authorized inpatient days, the hospital must
seek an authorization for additional inpatient days.
BLOCK
1
INSTRUCTIONS
Enter an X in the Medicaid box.
1a
4
5
Leave blank.
Enter the patients mailing address and telephone
number. Enter the street address on line 1, enter the city
and state on line 2, and enter the 5- or 9-digit zip code
and phone number on line 3.
BLOCK
INSTRUCTIONS
6-8
Leave blank.
99d
10ac
10d
BLOCK
INSTRUCTIONS
17
17a
Leave blank.
17b
18
BLOCK
INSTRUCTIONS
19
20
21
BLOCK
INSTRUCTIONS
22
23
24A
24B
BLOCK
INSTRUCTIONS
24C
24D
24E
24F
BLOCK
INSTRUCTIONS
24G
24H
24I
BLOCK
24J
INSTRUCTIONS
Enter the 10-digit NPI for the:
provider who performed the service if the provider is a
member of a group practice. (Leave blank if the provider
is a solo practitioner.)
supervising provider if the service was provided
incident to the service of a physician or nonphysician
practitioner and the physician or practitioner who
ordered the service did not supervise the provider.
(Leave blank if the incident to service was performed
under the supervision of the physician or nonphysician
practitioner.)
DMEPOS supplier or outside laboratory if the physician
submits the claim for services provided by the DMEPOS
supplier or outside laboratory. (Leave blank if the
DMEPOS supplier or outside laboratory submits the
claim.)
Otherwise, leave blank.
BLOCK
INSTRUCTIONS
25
26
27
28
29-30
Leave blank.
BLOCK
31
INSTRUCTIONS
Enter the providers name and credential (e.g., MARY
SMITH MD) and the date the claim was completed as
MMDDYYYY (without spaces). Do not enter any
punctuation.
32
32a
32b
Leave blank.
BLOCK
33
INSTRUCTIONS
Enter the providers billing name, address, and
telephone number. Enter the phone number in the area
next to the Block title. Do not enter parentheses for the
area code. Enter the name on line 1, enter the address
on line 2, and enter the city, state, and 5- or 9-digit zip
code on line 3. For a 9-digit zip code, enter the hyphen.
33a
33b
Leave blank.
BLOCK
INSTRUCTIONS
9a
BLOCK
INSTRUCTIONS
9b
9d
10a-c
10d
Leave blank.
11
11d
BLOCK
INSTRUCTIONS
28
29
30
BLOCK
INSTRUCTIONS
1a
21
BLOCK
INSTRUCTIONS
1a
19
Leave blank.
22
Leave blank.
29
30