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ACA > MODULE 4 > Flashcards

MODULE 4 Flashcards

1
Q

WHO FUNDS MEDICAID?

A

STATE & FEDERAL GOVERNMENT

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2
Q

WHO DOES MEDICAID PROVIDE COVERAGE FOR?

A

LOW INCOME CHILDREN, PARENTS / CAREGIVERS, PREGNANT WOMEN, AGED, BLIND, DISABLED

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3
Q

WHAT IS CHIP?

A

CHILDREN’S HEALTH INSURANCE PROGRAM - CREATED FOR CHILDREN WITH FAMILY INCOME TOO HIGH TO QUALIFY FOR MEDICAID

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4
Q

WHO DOES HIP COVER?

A

UNINSURED ADULTS 19-64 WITH UP TO 100% FPL

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5
Q

WHAT ARE THE PLAN FEATURES OF HIP?

A
  1. BASIC COMMERCIAL COVERAGE
  2. ANNUAL DEDUCTIBLE OF $1100 PER YEAR
  3. $500 IN PREVENTATIVE SERVICES COVERED BY INDIANA
  4. CO-PAYS FOR NON-EMERGENCY USE OF THE EMERGENCY ROOM.
  5. P.O.W.E.R. ACCOUNT - PERSONAL WELLNESS & RESPONSIBILITY ACCOUNT WHICH FUNDS THE DEDUCTIBLE USING BOTH STATE AND INDIVIDUAL CONTRIBUTIONS (2% OF INCOME)
  6. EMPLOYERS & NON-PROFITS CAN HELP WITH CONTRIBUTIONS
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6
Q

WHAT IS AN MCE?

A

MANAGED CARE ENTITY?

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7
Q

WHAT ARE THE THREE MCE’S FOR HHW & HIP?

A

MDWISE, ANTHEM AND MHS

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8
Q

HOW IS A MCE SELECTED?

A

ON THE APPLICATION, OR AUTO ASSIGNED 14 DAYS AFTER ENROLLMENT

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9
Q

HOW IS A PCP CHOSEN?

A

INDIVIDUALS CAN CHOOSE OR THEY WILL BE ASSIGNED ONE

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10
Q

WHAT IS CARE SELECT?

A

A PLAN FOR MEDICAID ENROLLEES WITH SPECIAL HEALTH NEEDS OR CHRONIC ILLNESSES

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11
Q

WHAT ARE SOME CATEGORIES OF ENROLLEES WHO WOULD HAVE CARE SELECT?

A

AGED, BLIND, DISABLED
WARD OF THE COURT
FOSTER CHILD
CHILD RECEIVING ADOPTION SERVICES

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12
Q

WHAT IS THE GOAL OF CARE SELECT?

A

TO COORDINATE CARE AND HELP TO MANAGE THE DISEASE

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13
Q

WHAT ARE SOME EXAMPLES OF QUALIFYING CONDITIONS FOR CARE SELECT?

A

ASTHMA, DIABETES, CONGESTIVE HEART FAILURE, CORONARY HEART DISEASE, COPD, HYPERTENSION, CHRONIC KIDNEY DIALYSIS, SEVERE MENTAL ILLNESS, SEVERE EMOTIONAL DISTURBANCE, DEPRESSION

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14
Q

WHAT IS A CMO?

A

CARE MANAGEMENT ORGANIZATION

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15
Q

WHO COORDINATES CARE FOR CARE SELECT?

A

CMO’S

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16
Q

WHAT POPULATIONS ARE COVERED BY TRADITIONAL MEDICAID?

A
  1. AGED, BLIND, DISABLED
  2. ADULTS RECEIVING WAIVERS OR ELIGIBLE DUE TO BREAST OR CERVICAL CANCER
  3. CHILDREN IN PSYCHIATRIC FACILITIES OR TITLE IV-E FOSTER CARE OR ADOPTION CARE CHILDREN
  4. REFUGEES WHO DON’T QUALIFY FOR ANOTHER CATEGORY.
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17
Q

WHAT IS M.E.D. WORKS ?

A

MEDICAID FOR EMPLOYEES WITH DISABILITIES

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18
Q

WHAT ARE THE CRITERIA FOR M.E.D. WORKS?

A
  1. MUST BE WORKING AND DISABLED
  2. 16-64
  3. BELOW 350% FPL
  4. BELOW ASSET LIMIT (SINGLE - $2000; COUPLE - $3000)
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19
Q

WHAT ARE THE BENEFITS OF M.E.D. WORKS?

A

RECEIVE FULL MEDICAID BENEFITS AND CAN ALSO HAVE EMPLOYER INSURANCE IF APPLICABLE.

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20
Q

WHAT IS HCBS?

A

HOME AND COMMUNITY BASED SERVICE WAIVER

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21
Q

WHAT DOES A WAIVER DO?

A

KEEPS INDIVIDUALS IN THEIR HOMES RATHER THAN NEEDING TO GO TO AN INSTITUTION BY PROVIDING HOME-BASED SERVICES.

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22
Q

WHAT ARE THE ELIGIBILITY CRITERIA FOR WAIVERS?

A
  1. INCOME LESS THAN 300 % SSI BENEFIT
  2. INCOME LESS THAN $2130/ MO AS OF 1/1/13
  3. MEETS “LEVEL OF CARE” - MEDICAL CONDITION, INTELLECTUAL DISABILITY
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23
Q

WHAT IS THE GOAL OF THE MEDICAID FAMILY PLANNING PROGRAM?

A
  1. PREGNANCY PREVENTION / DELAY
  2. PROVIDE FAMILY PLANNING SERVICES & SUPPLIES
  3. CITIZENSHIP / IMMIGRATION ELIGIBILITY REQUIREMENTS
  4. NOT PREGNANT
  5. NOT HAD A HYSTERECTOMY
  6. NOT HAD A STERILIZATION PROCEDURE
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24
Q

WHAT IS THE GOAL OF A SPEND DOWN?

A

TO ASSIST INDIVIDUALS WHO HAVE HIGH MEDICAL NEEDS BUT DO NOT MEET MEDICAID ELIGIBILITY REQUIREMENTS

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25
Q

HOW DO YOU BECOME ELIGIBLE FOR A SPEND DOWN?

A
  1. INCOME TOO HIGH FOR MEDICAID

2. MEET OTHER MEDICAID CRITERIA: AGE, BLINDNESS, DISABILITY

26
Q

WHAT IS THE GOAL OF THE BREAST & CERVICAL CANCER PROGRAM?

A

PROVIDE COVERAGE TO WOMEN WHO HAVE BREAST OR CERVICAL CANCER

27
Q

HOW DOES A WOMAN BECOME ELIGIBLE FOR THE BREAST & CERVICAL CANCER PROGRAM?

A

DIAGNOSED THROUGH THE INDIANA DEPT OF HEALTH BREAST & CERVICAL CANCER SCREENING PROGRAM

OR

AGE 19-64
NOT OTHERWISE ELIGIBLE FOR MEDICAID
INCOME LESS THAN 200%
NEED TREATMENT FOR THE CANCERS
NO HEALTH INSURANCE THAT COVERS THESE TREATMENTS
28
Q

WHAT ARE THE ELIGIBILITY REQUIREMENTS FOR CHILDREN IN THE HHW PROGRAM?

A

AGES 0-19

INCOME UP TO 250% FPL

29
Q

WHAT ARE THE REQUIREMENTS FOR FORMER FOSTER CHILDREN TO BE ENROLLED IN MEDICAID?

A

FOR AGES 18-21 - UP TO 210% FPL

FOR AGES 18-25 - NO INCOME REQUIREMENTS; ENROLLED IN MEDICAD ON 18TH BIRTHDAY

30
Q

WHAT ARE THE REQUIREMENTS FOR PARENTS AND CARETAKERS TO BECOME ELIGIBLE FOR MEDICAID?

A

MUST BE CARETAKER OF DEPENDENT CHILD; UP TO 250% OF FPL

31
Q

HOW CAN PREGNANT WOMEN BECOME ELIGIBLE FOR MEDICAID

A

INCOME UP TO 208% OF FPL

PREGNANT

32
Q

HOW OLD MUST CHILDREN BE TO QUALIFY FOR MEDICAID IF THEY ARE IN A CERTIFIED PSYCHIATRIC FACILITY? ARE THERE INCOME REQUIREMENTS?

A

19-21

YES. 250%

33
Q

HOW LONG CAN CHILDREN RECEIVE MEDICAID UNDER THE ADOPTION ASSISTANCE PROGRAM?

A

UNDER AGE 19

34
Q

HOW LONG CAN FOSTER CHILDREN RECEIVE MEDICAID?

A

UNDER 19

CURRENT FOSTER CHILD

35
Q

WHAT ARE THE INCOME LIMITS FOR AGED, BLIND, DISABLED?

A

$1066 MARRIED / MO

$710 SINGLE

36
Q

WHAT CONSTITUTES “AGED”?

37
Q

HOW DO YOU QUALIFY UNDER THE “BLIND” CATEGORY?

A

MEETS DEFINITION OF BLINDNESS OR RECEIVES SSI OR SSDI FOR BLINDNESS

38
Q

WHAT ARE THE QUALIFICATIONS FOR M.E.D. WORKS?

A

UP TO 350% FPL
16-64
MEET DEFINITION OF DISABILITY

39
Q

WHAT IS THE INCOME LIMIT FOR HIP?

40
Q

WHAT IS THE INCOME LIMIT FOR FAMILY PLANNING?

41
Q

WHAT IS THE INCOME LIMIT FOR MEDICARE SAVINGS PROGRAM QMB (PART A)

42
Q

WHAT IS THE INCOME LIMIT FOR MEDICARE SAVINGS PROGRAM SLMB (PART A)

43
Q

WHAT IS THE INCOME LIMIT FOR MEDICARE SAVINGS PROGRAM QI (PART A)

44
Q

WHAT IS THE INCOME LIMIT FOR MEDICARE SAVINGS PROGRAM QDW (PART A DUE TO EMPLOYMENT STATUS)

45
Q

WHAT ARE THE CITIZENSHIP REQUIREMENTS FOR MEDICAID?

A

US CITIZENS
US NON-CITIZEN NATION
LAWFUL PERMANENT RESIDENTS ELIGIBLE FOR FULL MEDICAID AFTER 5 YEARS

46
Q

WHAT ARE SOME EXCEPTIONS TO THE CITIZENSHIP RULES?

A

MEDICARE ENROLLEES
FOSTER CARE KIDS
RECEIVING SSI OR SSDI
NEWBORNS WITH A MOM ON MEDICAID

47
Q

ALL MEDICAID APPLICANTS MUST PROVIDE A SSN UNLESS…

A 
NOT ELIGIBLE TO RECEIVE A SSN
DON'T HAVE A SSN
RELIGIOUS REASONS
ONLY ELIGIBLE FOR EMERGENCY SERVICES
NEWBORN
RECEIVING REFUGEE CASH ASSISTANCE
ALREADY APPLIED FOR SSN. NO NUMBER YET
48
Q

WHAT OTHER BENEFITS MUST BE APPLIED FOR AS A REQUIREMENT TO THE MEDICAID APPLICATION?

A 
PENSIONS FROM LOCAL, STATE, FEDERAL GOV'T
RETIREMENT BENEFITS
DISABILITY
SOCIAL SECURITY BENEFITS
VA BENEFITS
UNEMPLOYMENT
MILITARY BENEFITS
RAILROAD BENEFITS
WORKER'S COMP BENEFITS
HEALTH & ACCIDENT INSURANCE BENEFITS
49
Q

IF AN APPLICANT HAS ANOTHER INSURANCE AND IS APPROVED FOR MEDICAID, WHICH IS BILLED FIRST?

A

THE OTHER INSURANCE. MEDICAID IS ALWAYS LAST EXCEPT IN THE CASE OF CSHCS.

50
Q

WHAT IS MAGI?

A

STANDARDIZED INCOME COUNTING ACROSS ALL STATES

51
Q

WHO IS EXEMPT FROM MAGI?

A

AGED, BLIND, DISABLED

52
Q

HOW IS MAGI COMPUTED?

A

COUNT TAXABLE INCOME FOR TAX FILER, ALL TAX DEPENDENTS (MAY INCLUDE STEP-PARENTS, CHILDREN, SIBLINGS)
DO NOT COUNT ASSETS, NON-TAXABLE INCOME

53
Q

WHO IS NOT REQUIRED TO USE MAGI?

A 
AGED, BLIND, DISABLED
NEED LONG TERM CARE
BREAST & CERVICAL CANCER PROGRAM RECIPIENTS
FORMER FOSTER CHILDREN UNDER 26
MEDICARE COST-SHARING APPLICANTS
NEWBORNS
54
Q

WHAT INCOME WILL COUNT FOR THOSE NOT USING MAGI?

A

THE CURRENT INCOME COUNTING RULES

CERTAIN ASSETS

55
Q

WHAT PROVISIONS ARE MADE FOR THE SPOUSE OF SOMEONE WHO IS IN A NURSING HOME TO HAVE RESOURCES TO LIVE ON?

A

COMMUNITY SPOUSE MAY KEEP ALL PERSONAL INCOME
MAY KEEP 1/2 JOINTLY OWNED ASSETS
IF THIS AMT IS LESS THAN $1939, MAY KEEP SOME OF INSTITUTIONALIZED SPOUSE’S INCOME

56
Q

HOW WILL INDIANA APPLICATIONS FOR HEALTH COVERAGE BE ACCEPTED?

A 
ONLINE
PHONE
FAX
MAIL
IN PERSON AT DFR
57
Q

STARTING IN OCTOBER, HOW WILL PV’S BE HANDLED?

A

NAVIGATORS WILL BE ABLE TO VERIFY ELIGIBILITY IN MOST CASES ELECTRONICALLY AND ONLY HAVE TO ASK APPLICANTS FOR PAPER DOCUMENTS WHEN THE ELECTRONIC DATA IS INCONSISTENT WITH THE APPLICATION

58
Q

WHAT IS PRESUMPTIVE ELIGIBILITY?

A

FSSA AUTHORIZES HEALTH CARE PROVIDERS TO ASK UNINSURED PATIENTS TO SCREEN POTENTIAL MEDICAID RECIPIENTS QUESTIONS TO COMPLETE A PE APPLICATION. IF THE PATIENT MEETS THE PE REQUIREMENTS FOR MEDICAID, THEY ARE CONSIDERED PRESUMPTIVELY ELIGIBLE FOR MEDICAID. THE QP IS PAID FOR SERVICES AND THE PATIENT COMPLETES THE APPLICATION FOR HEALTH CARE COVERAGE. IF ELIGIBLE, COVERAGE CONTINUES, IF NOT, COVERAGE WILL END

59
Q

WHAT CATEGORIES OF PEOPLE WILL PE COVER?

A

CHILDREN UNDER 19
LOW INCOME PARENTS/CARETAKERS
FAMILY PLANNING ELIGIBLE
FORMER FOSTER CARE CHILDREN UP TO 26

60
Q

WHAT ITEMS CAN BE APPEALED?

A

TERMINATION OF BENEFITS
SUSPENSION OF BENEFITS
REDUCTION OF BENEFITS

61
Q

HOW OFTEN IS REDETERMINATION?

A

EVERY 12 MONTHS

62
Q

HOW IS REDETERMINATION DONE?

A

STATE CHECKS ELECTRONIC DATA, IF THERE IS ENOUGH INFORMATION TO RENEW, COVERAGE IS RENEWED, IT IS, IF NOT, ENROLLEE IS CONTACTED.

ACA (4 decks)

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