CMC Medicare & Medicaid Funding 3 — Questions and Answers
Question 1: Which federal agency administers the Medicaid program at the national level and sets minimum coverage standards?
- The Social Security Administration (SSA)
- The Centers for Medicare & Medicaid Services (CMS) (Correct answer)
- The Department of Veterans Affairs (VA)
- The Health Resources and Services Administration (HRSA)
Correct answer: The Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) administers Medicaid at the federal level and sets minimum coverage and eligibility requirements that states must follow.
Question 2: A Medicaid waiver program that allows states to provide home and community-based services (HCBS) instead of institutional care is authorized under which section of the Social Security Act?
- Section 1905
- Section 1915(c) (Correct answer)
- Section 1902(a)
- Section 1935
Correct answer: Section 1915(c)
Section 1915(c) of the Social Security Act authorizes states to operate Home and Community-Based Services waiver programs as an alternative to institutional care.
Question 3: For a beneficiary who qualifies for both Medicare and Medicaid (dual eligible), which program is billed FIRST for a covered mobility device?
- Medicaid, because it has broader coverage
- Medicare, as the primary payer (Correct answer)
- The program whose coverage limit has not yet been reached
- The supplier chooses which program to bill first
Correct answer: Medicare, as the primary payer
For dual-eligible beneficiaries, Medicare is always the primary payer and Medicaid is billed second to cover remaining cost-sharing or items Medicare does not cover.
Question 4: A state Medicaid program wants to cover power wheelchairs but imposes a prior authorization requirement. This is:
- Prohibited because Medicare already sets the standard
- Permissible as states may add utilization management requirements within federal guidelines (Correct answer)
- Only allowed if CMS waives the standard Medicaid rules
- Allowed only for beneficiaries under age 21
Correct answer: Permissible as states may add utilization management requirements within federal guidelines
States have broad flexibility to impose prior authorization and other utilization management requirements for Medicaid-covered services, including mobility equipment.
Question 5: Under Medicaid, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children under age 21 requires that:
- Only items listed in the state plan are covered for children
- Any medically necessary service must be covered even if not in the state plan (Correct answer)
- Children must meet the same prior authorization criteria as adults
- Mobility equipment for children is categorically excluded
Correct answer: Any medically necessary service must be covered even if not in the state plan
EPSDT mandates that all medically necessary services be covered for Medicaid-eligible children under 21, even if the service is not included in the state's standard Medicaid plan.
Question 6: Which Medicaid eligibility category most commonly covers adults with physical disabilities who need complex mobility equipment?
- Mandatory categorically needy adults without disabilities
- Medically needy pregnant women
- Disabled individuals receiving Supplemental Security Income (SSI) (Correct answer)
- Undocumented immigrants in emergency-only coverage
Correct answer: Disabled individuals receiving Supplemental Security Income (SSI)
Adults with disabilities who receive SSI are categorically eligible for Medicaid and represent the primary population requiring complex rehabilitation mobility equipment.
Question 7: When a Medicaid-funded wheelchair must be replaced due to wear beyond repair, the standard replacement cycle under most state policies is approximately:
- 1 year
- 3 years
- 5 years (Correct answer)
- 10 years
Correct answer: 5 years
Most state Medicaid programs align with Medicare's 5-year replacement guideline for complex power wheelchairs, though states may vary.
CMC Medicare & Medicaid Funding 3
Which federal agency administers the Medicaid program at the national level and sets minimum coverage standards?