Medicare and Medicaid Program

Medicare is categorized into different parts that accommodate different members of the society:

Part A and B Qualifications

For an individual to be considered as eligible for Medicare part A and B, they are required to be a U.S citizen or a permanent and legal resident for a minimum of five continuous years. There are other conditions that also need to be sustained for the eligibility to go through.

One should be aged 65 years old or more and qualified for social security. In this, one becomes automatically engaged in the Medicare Part A which covers hospital insurance upon attaining the age of 65 and getting a green light for Social Security. However in such a case, Medicare Part B on Medical Insurance will require enrolling. Those individuals receiving their benefits from Social Security or Railroad Retirement Board are qualified automatically for the part A and B upon hitting the age limit of 65. Individuals aged 65 but still working do not have automatic Medicare Part B and need to enroll upon reaching the age of 65 years old.

An individual who is permanently disabled and has been getting the benefits for the disability for a minimum of two years gets automatically qualified for the Medicare Part A and B. The individuals with the end-stage renal disease (ESRD) that is characterized by permanent kidney failure with solution being dialysis or kidney transplant are also not entitled to an automatic enrollment and therefore required to sign up for Medicare. Individuals with Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis, ALS) are entitled to an automatic Medicare part A and qualify for Part B upon the commencement of their disability benefits (Barry, 2016).

Medicare Part C

This part is known as Medicare Advantage and is an alternative to Medicare Part A and B. it is issued through private insurers. Individuals seeking this coverage ought to be enrolled under Medicare Part A and B and living within the service area of the Advantage plan being targeted. The plan is not available to individuals with end stage renal disease.

Medicare Part D

This part is meant to provide cover for the prescription drugs and is offered through private insurers who are approved by Medicare. It requires a person to be engaged in the Medicare Part A and part B and residing in the service region.

Medicaid

The Medicaid was established through efforts of the federal and state governments as well as the Children’s Health Insurance Program. Its main aim was to offer health coverage to more than 72.5 million Americans under the category of children, expectant women, parents, the aged, and persons with disability. It became the sole largest source of health coverage in the country.

Eligibility

The federal law requires states to offer the coverage for groups such as low income families, qualifying expectant women, children, and individuals benefiting from Supplemental Security Income. Different states included other options and expanded the categories of groups that may be covered. 

Determination of Eligibility 

The first criteria for eligibility are pegged on financial eligibility where the Modified Adjusted Gross Income (MAGI) is used. MAGI measures the financial eligibility for Medicaid, CHIP, and premium tax credits as well as the cost sharing reductions in the insurance marketplace. This method is used mostly for children, pregnant women, parents, and adults. The methodology relies on taxable income and tax filing relationships to figure out the financial eligibility for Medicaid.

The non-financial eligibility criteria for Medicaid includes: the beneficiaries need to be residents of the state where they are expected to receive the Medicaid. It is also requires that for individuals to qualify they need to be citizens or qualified non-citizens. Other measures used for various groups include age, pregnancy, or parenting conditions.

Modification to the Qualifications in Favor of the Vulnerable Population

Medicaid and Medicare are provided and governed by the Affordable Care Act. Under this law, the qualifications granted at times treat individuals in an arbitrary and unfair manner through differential subsidies. Individuals earning less than the average wage acquire more benefits from the federal government. There is need to change these perverse incentives that tend to accord different treatment for individuals at the same income level  based on the source of the insurance, hours of work, and number of colleagues at work. This creates a negative impact to the coverage of the vulnerable groups.

The qualification put in place and laws governing these insurance programs require insurers to charge same premium with no regard to health status and accept all who apply. The results of this are the over-charging of the healthy and under-charging the ailing.  This has seen the insurers try to attract the healthy from whom they make a profit and tend to avoid the sick who add to their expenses overhead (Goodman, 2015).

Medical Billing for Medicare

Medicare operates as a single-payer healthcare system that makes payments to the insurance companies for people enrolled under its diversified programs. The medical billing officers submit claims to the relevant authorities for processing after an individual who has received services under their Medicare plan. The medical billing officers are required to input information from a provider’s super bill into compatible medical billing software.  The information offered includes provider information, patient information, services offered, and other required medical codes. The information is then printed out CMS-1500 claim for that is sent through mail or electronically to MAC for processing (Beck & Margolin, 2007).

Part A of Medicare is billed by a medical billing specialists using the UB-04 medical claim form. This form is the uniform institutional provider claim form accepted for billing third-party providers. It is the only hardcopy claim form that CMS gets from institutional providers. 

The billing of the Medicare Part B of preventive care requires filing claims using the CMS-1500 form that is the standard claim form used by healthcare providers for billing Medicare carriers. The files are under the control the National Uniform Claim Committee (NUCC) (Beck & Margolin, 2007).

Claims for Medicare Part C and D are issued through a private insurer but never through Medicare. For Part C and D of the Medicare are never filed under the Medicare Claims. This is because the private health plan carriers are in contract with Medicare to receive a pre-determined amount for each member monthly. Part D is not constant as the coverage is pegged on the drugs issued. The claims under Part C and D of Medicare are treated like claims on private health plan carriers (Beck & Margolin, 2007).

The Impact that the ACA has had on Medicare and Medicaid Recipients

The Affordable Care Act (ACA) was developed with an aim of raising the health insurance coverage for individuals under the age of 65 years, enhance better performance of health care system, and reduce the rate of growth of cost of healthcare. The ACA in a way addressed the gaps that existed in the Medicare preventive and prescription drug benefit. This was achieved through creating a way for new payment methods that helped the improvement of value of care that the recipients acquired. The ACA introduced change to the Medicare Advantage program and gave the recipients an alternative of receiving their Medicare benefits through private plans. These changes aimed at providing incentives for these plans as a means of improving quality and patient’s healthcare experiences. It also helped recipients make a choice on the plans with higher quality and lower cost.

The Affordable Care Act (ACA) law provided an alternative to the states to increase the capacity of their Medicaid programs. The increase in the expenses due to this expansion would be covered by the state. This expansion has seen the states include all adults with income at or less than 138% of the federal poverty level. It was noted that after enacting the ACA, the enrollment of Medicaid received an additional 10.8 million Americans (Blumenthal, Abrams, & Nuzum, 2015). The ACA also provided for subsidized private insurance for individuals not categorized as poor but not covered under the workplace insurance coverage.

References

Barry, P. (2016). Do You Qualify for Medicare? Health Medicare Resource Center.

Beck, D., & Margolin, D. (2007). Physician Coding and Reimbursement. The Ochsner Journal, 8-15.

Blumenthal, D., Abrams, M., & Nuzum, R. (2015). The Affordable Care Act at 5 Years. The New England Journal of Medicine.Goodman, J. (2015). Six Problems With the ACA tha Aren’t Going Away. Retrieved from http://healthaffairs.org/blog/2015/06/25/six-problems-with-the-aca-that-arent-going-away