6202 Final Latest Questions And
Answers!!!
Since its inception, Medicaid (also called Title 19 of the Social Security Act) was originally
designed to finance health care services for the indigent, and therefore it has been almost
entirely a tax-payer funded program. From the very beginning, Medicaid has been what we call
a means-tested program. What does that mean? - ANS -Eligibility depends on financial
resources
-Each state administers their own Medicaid program under
-Federal guidelines, and Medicaid is jointly financed by both state and Federal governments
-Federal government provides matching funds to each of the states based upon that state's per
capita income
What are the three main categories of people who are automatically eligible for Medicaid? -
ANS 1.Families with children receiving support under the Temporary Assistant for Needy
Families (TANF) program
2.People receiving Supplement Security Income (SSI), which includes the elderly, blind, and
disabled with low income
3.Children and pregnant women whose family income is at or below 133% of the Federal
Poverty Level
About 9 million people are called dual-eligible beneficiaries. What does that mean? - ANS
-They are eligible for both Medicaid and Medicare.
-Dual-eligibility beneficiaries have extensive health care needs because of chronic conditions,
one or more disabilities, or a need for long-term care
-Example - low-income elderly and disabled young adults who are entitled to Medicare, but also
become eligible for some level of assistance under Medicaid
If you are in the C-suite of a large hospital system, what would you expect to happen, and what
would you therefore have to plan for, if your state expanded Medicaid coverage, based upon
observation and research findings? - ANS -increased in the use of hospital emergency
departments
-increased use of Eds, even over a number of years.
-In the post-affordable Care Act era, Medicaid-paid use of Eds increased by 27%.
- Look at how you are staffing your ED.
There are a couple of perplexing and ongoing problems with the Medicaid program, and it would
affect just about any healthcare organization within which you might work. What are those and
explain? - ANS -#1 problem: comparatively poor reimbursement for providers, and the
,result of this is that many physicians and some other providers do not serve Medicaid-covered
patients
**Medicare, Medicaid reimburses providers only a fraction of what Medicare pays providers for
the same or similar level of services
#2 churning. The constant exit and reentry of beneficiaries in the Medicaid system because their
eligibility tends to change a lot based upon their wildly fluctuating income from month to month.
-Data suggest that up to 30% of Medicaid beneficiaries will lose their eligibility within 6 months,
and almost half lose it within 12 months.
-Churning disrupts access and continuity of care
What is CHIP - ANS -Children's Health Insurance Program (CHIP)
-Initiated in 1997 as part of the Social Security Act
What does CHIP do? - ANS -Intended to address the plight of uninsured children whose
family income exceeded the Medicaid threshold levels, which made them ineligible for Medicaid,
however for a host of other reasons did not have access to an employer-sponsored plan
Federal government provides funds in the form of block grants to states to cover children and
adolescents up to age 19 years.
-Federal law requires that ineligibility for Medicaid be established before a family is approved for
CHIP coverage benefits.
-Each state is allowed to establish its own eligibility criteria for CHIP, but those criteria have to
comply with Federal guidelines
CHIP financing is shared between federal and state governments.
Has CHIP been effective? If not, why, and if so, in what ways? - ANS Yes
-Impact on reducing the number of uninsured children
-Improving access, continuity of care, and quality of care for children in all racial/ethnic groups
and in reducing racial and ethnic disparities in access, unmet needs, and continuity of care.
What is TRICARE and whom does it serve? - ANS The insurance arm of the military health
care system
-Beneficiaries are able and allowed to obtain health care through the Department of Defense
medical facilities or through services purchased from civilian providers.
What is the Veterans Health Administration (VHA/VA) - ANS Health services branch of the
US Department of Veterans Affairs.
-The VA operates the largest integrated health service system in the entire US.
-Operates hospitals, outpatient clinics, nursing homes and other facilities
-
, Whom does the Veterans Health Administration (VHA/VA) serve? - ANS -Provides services
to about 8.7 million veterans, and its Office of Research and Development focuses on health
issues that impact veterans.
-Originally developed to handle war-related injuries and to rehab members w/ war-related
disabilities. original mission was expanded, now includes non-service-related conditions actually
accounts for the most of the care provided
What are third-party payers? - ANS -insurance companies
-Managed Care Organizations
-Blue Cross/Blue Shield
-Government.
+2 Other parties, Patient and Provider.
What is the function of third party payers? - ANS The third-party-payer function has two
major functions
1. Determining the methods and amounts of reimbursements
2. The actual payment of the bill after services have been provided.
Charge - ANS Fee set by a provider
Rate - ANS a price set by any third-party payer
-Also referred to as reimbursement
Fee schedule - ANS An index of charges listing individual fees for each type of service
-
Claim - ANS in order to receive payment for services, the provider has to file a claim with
the third-party payer
What is Fee for Service? - ANS Fee for service - oldest method of reimbursement and is
still in existence, but its use has been greatly reduced
-Assumes that healthcare is provided in a set of identifiable and individually distinct units of
services
Ex: x-rya, urinalysis, tetanus shot
-Providers established their own fee-for-service charges and insurers passively paid the claims
-Insurance started to limit reimbursement to a usual, customary, and reasonable (UCR) amount.
-Each third-party payer determined on their own what the UCR should be
-Providers would then do is what is called a balance bill, which is to ask the patients to pay the
diffrence between the actual charges and the UCR payments received from the third-party
payers.
-Problem with this system is that providers have an incentive to deliver additional services that
may not always be essential
