Medicare and Medicaid

The establishment of the health insurance program referred to as Medicare was as a result of the enactment of the Social Security Act. The purpose of this act was to provide a compliment to the benefits of retirement and disability to the aged population (65 years and above). The enactment of this act in 1965, therefore, assured the elderly that there will be medical coverage and physician service and guarantee admission to the hospital without any of them running into a financial catastrophe. However, Medicare is more inclined in providing the healthcare benefits to those with retirement benefits. Medicaid thus steps in and provides healthcare to the low income elderly by providing assistance with Medicare’s financial obligations. Medicaid is the largest financier of the medical insurance to the most America’s poorest populations.

Medicare Eligibility Criteria

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Medical assistance is not provided by the Medicare and Medicaid to the financially challenged populations. One is only eligible for these benefits if they satisfy some eligibility criteria. The eligibility of Medicare is sub-divided into four parts of eligibility criteria. However, parts A and B of the eligibility criteria must meet some conditions: One must be a citizen of the United States of America or a continuous and legal resident of the U. S. for a period exceeding five years. Social Security eligible elderly who are 65 years and above must some of the conditions described below.  

Medicare part A is automatically enrolled to the elderly people is they reach and age of 65 and above. This is referred to as hospice Insurance and is only applicable to those who are eligible for Social Security benefits. If anyone eligible for Part A wished to be eligible for part B, then further enrolment is required. Anyone eligible for Social Security and Railroad Retirement disability benefits for a period of 24 months and government employees who are under coverage of Medicare only and have been disabled for a period of exceeding 29 months.

 Elderly people who are experiencing a permanent kidney failure and are in need of dialysis or may need a kidney transplant needs to sign up for Medicare because the enrolment is not automatic (DeWalt, Oberlander, Carey and Roper, 2005). Also, those people diagnosed for Lou Gehrig’s disease automatically get part and Part B beginning from the month that their disability benefits begin.

It is also very important to note that if an individual or their spouse paid taxes for a period of 10 years. However, premium amounts are different depending upon the situation, for example, for the individuals not eligible for a premium free Part A is expected to pay premium of $411. Those enrolled for part B before 2016 are required to pay monthly premiums of $104.90. A premium of $121.80 is to Part B applicants are they enrolled for the first time in 2016, those who are currently not under the Social Security benefits and Railroad Retirement Board, are dual eligible, and those that are billed directly for their Part B premiums (Ng, Harrington and Kitchener, 2010).

      For one to be eligible for part C of the Medicare plan, one must first be eligible for part A and part B of the healthcare plans. It is offered by private insurers and one is expected to be living in service area of a Medicare Advantage Plan. Those with and end-stage renal disease are not eligible unless there are some exceptions. Paying premiums for Part A and part B must also be continued.

Medicare-approved private insurers provides Medicare part D. It covers the prescription of drugs and one must be eligible for Medicare and part A and part B and also has to be living in the service area for the prescription plan wished to enroll.  

Medicaid Eligibility Criteria

The aim of Medicaid is not provide healthcare to all the poor people. It only provides medical assistance to the people in designated groups. The criterion for low income is only one of the tests of medical eligibility for those in the designated groups. Although different states have different criteria for determining Medicaid eligibility, the following groups are defined to be “Categorically needy” are therefore eligible for Medicaid:

            Families that have children and their income are limited. These families have to meet the requirement for the aid to families as stipulated by the Social Security Act of 1931. Pregnant women and all children hailing from families whose income is below 133% of FPL are also eligible for Medicaid. Other groups include infants born of parents eligible for Medicaid and special protected groups. In general, the eligibility criteria is based upon the size and income of the family, specific medical needs of the applicant, resources or assets that the family has (excluding children, pregnant mothers, and adults under Indiana Healthy Plan) and age of the applicants (Hoffman, Klees and Curtis, 2000).

             Medicaid is meant to provide services such as family planning care, the costs of drugs prescription, inpatient and outpatient services, dental and mental healthcare, pediatric services and physical, occupational and speech therapy. However, unlike Medicare services, Medicaid varies widely from state to state and the services described are the most common services offered by almost all the states.  

How Medicare effects Billing

Billing in healthcare occurs just like other third-party claims. All claims by every biller are sent directly to Medicare of Medicaid. The processing is then done by the Medicare Administrative Contractor (MAC), who does the evaluation in a period of about 30 days. Part A and part B of Medicare are usually referred to as traditional Medicare, despite the fact that they may also be required to similar protocols followed by private third-party payers, almost all their information can be obtained from medical coder. UB-04 and CMS-1500 forms require to be filled by Part A and Part B respectively in case the claims are to be done manually. However, manual claims are highly discouraged due the complications that arise.

Billing of Part C and D is more complicated as compared to billing of part A and B. Since Medicare is service that is contributed partly by the federal government and partly by the holder, the billers are restricted from billing Medicare for Part C. In part D, only licensed providers are allowed to bill Medicare. Unlicensed billers are only allowed to bill the total amount to the patient. 

Impact of ACA on Medicare Recipients

One of the greatest impacts of Medicare is the offering coverage to the poor populations who have otherwise not have afforded the medical services (DeWalt et al., 2005). The recipients are able to get more preventive services for less due to services such as mammograms and colonoscopies and annual visits for checkups (Rosenbaum, 2011). They are also able to access expensive drugs at an incredible discount (60%) in the pharmacies. There is also the assurance of a future premium savings as the Medicare services are expected to extend up to at least year 2029. 


DeWalt, D. A., Oberlander, J., Carey, T. S., & Roper, W. L. (2005). Significance of Medicare and Medicaid Programs for the Practice of Medicine. Health Care Financing Review27(2), 79–90.

Hoffman, E. D., Klees, B. S., & Curtis, C. A. (2000). Overview of the Medicare and Medicaid Programs. Health Care Financing Review22(1), 175–193.

Ng, T., Harrington, C., & Kitchener, M. (2010). Medicare And Medicaid In Long-Term Care. Health Affairs, 29(1), 22-28.

Rosenbaum, S. (2011). The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice. Public Health Reports126(1), 130–135.

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