Dsaeggern Medical Insurance Case Study

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Valerius−Bayes−Newby−Seggern: Medical Insurance: An Integrated Claims Process Approach, Third Edition IV. Payers 11. Medicaid © The McGraw−Hill Companies, 2008 Medicaid CHAPTER OUTLINE The Medicaid Program Federal Eligibility State Programs Medicaid Enrollment Verification Covered and Excluded Services Types of Plans Payment for Services Third-Party Liability Claim Filing Guidelines Medicaid Claim Completion Learning Outcomes After studying this chapter, you should be able to: 1. Describe the federal Medicaid eligibility requirements. 2. Discuss the effects of the Welfare Reform Act on Medicaid eligibility. 3. Explain the difference between categorically needy and medically needy. 4. Describe the income and asset guidelines used by most states to determine eligibility. 5. List the services that Medicaid usually does not cover. 6. List the types of…show more content…
In a spend-down program, individuals are required to spend a portion of their income or resources on health care until they reach or drop below the income level specified by the state. The concept is similar to an annual deductible, except that it resets at the beginning of every month. Each month, the enrollee pays a portion of incurred medical bills, up to a certain amount, before the Medicaid fee schedule takes effect and Medicaid takes over payments. For example, a patient who has a $100 spend-down visits the physician on March 3 and is billed $75. The patient is responsible for paying the entire $75. Later in the month, she visits the physician again and is charged $60. She must pay $25, and Medicaid will pay the remaining $35. At the beginning of the next month, she is once again responsible for the first $100 of charges. The spend-down amount varies depending on the patient’s financial resources. Many states also extend benefits to other groups of individuals. For example, most states offer coverage to people described as medically

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