After you finish this lesson, you will be able to:

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• Define Medicaid
• Verify the eligibility of Medicaid patients
• Describe CHIP and why it was developed
• Explain how Medicare and Medicaid are related

Medicaid is a social welfare program that offers health care to those with low income and few resources. It is funded jointly by the federal and state governments.

Major federal guidelines are administered by the Centers for Medicare and Medicaid Services (CMS). Within those guidelines, states create their own plans and eligibility requirements.

Because each state administers its own Medicaid program, eligibility varies from state to state. All states must enroll the categorically needy, or those who meet certain financial limitations.

This includes:

• Families with children who fall below a certain income level
• Elderly and disabled who are eligible for Supplemental Security Income (SSI) benefits
• Some states will also offer Medicaid benefits to the medically needy.

Almost every state covers:

• Children of parents eligible for public assistance
• Pregnant, single women below the poverty line
• The physically disabled

Historically Medicaid has only covered children. Due to healthcare reform during the 2010's, the Medicaid program has been expanded to cover adults.

Each state determines its own coverage and eligibility requirements, within federal guidelines.

Each Medicaid recipient should have an ID card. Medicaid ID cards may look different from private insurance ID cards.

The assistant should ask to see this card and make a copy of it upon the patient's first visit.

Important information to find on the Medicaid ID card includes:

• The patient's name
• Dates of eligibility
• Insurance plan information

The assistant should also check the patient's photo to verify identity.

A patient's continued Medicaid eligibility should be checked upon each visit before providing treatment.

These common verification methods may be used to check Medicaid eligibility:

• Automated Voice Response (AVR) system
• Online Verification System
• Point-of-Sale (POS) device
• Speaking to a Medicaid Representative

Automated Voice Response (AVR) system: AVR is a telephone system that provides an automated response to a caller. The response message confirms or denies a patient's eligibility.

Online Verification System: Online verification is an Internet system that provides information electronically, and it is accessed by visiting the appropriate Medicaid website.

Point-of-Sale (POS) device: A POS device works just like a credit card reader. The device reads the information contained on a magnetic strip on the Medicaid ID card. It will verify or deny eligibility immediately.

Speaking to a Medicaid Representative: Sometimes, the best way to verify a patient's Medicaid eligibility is to speak to an insurance company representative. This is especially helpful when there are questions regarding the Medicaid coverage.

Medicaid does not process its own claims. Each state chooses a fiscal intermediary (FI), or an outside company that contracts annually to process claims.

The Children's Health Insurance Program, or CHIP, is a low-cost insurance program for children.

• The federal government funds 50% of the program, and the state funds the other 50%.
• Each state decides who and what to cover, however they can not cover below the level mandated by the federal government.
• Some states have used CHIP funds to expand their Medicaid programs, while others keep the two programs entirely separate.

Generally, CHIP covers children of families who earn too little to pay for private coverage but earn too much to be eligible for Medicaid benefits. Some states choose to cover certain adults as well, such as the parents of children who are eligible for CHIP and pregnant women.

Some people are eligible for both Medicare and Medicaid benefits. This can be called dual eligibility, dual enrollment, or simply Medi/Medi. Medi/Medi is for the elderly or disabled who also have severe financial limitations.

If a patient is enrolled in both Medicare and Medicaid, Medicaid will pay the cost-sharing portions of Medicare Parts A and B.

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However, Medicaid coverage must always be secondary to Medicare.

In this lesson, you learned that:

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• Medicaid is a federal program for the needy governed by each state. Patients below a certain income may qualify for Medicaid benefits, depending on each state's specific policy.
• CHIP is a state-funded insurance program that covers children who are not eligible for Medicaid coverage.
• A patient's Medicaid eligibility should be confirmed upon each visit. Methods of doing this include Automated Voice Response (AVR) systems, Electronic Data Interchanges (EDI), and Point-of-Sale devices, and speaking to a Medicaid representative.