February 11, 2016
Although Medicare and Medicaid are often mentioned together whenever the question of insurance pops up, both the programs are quite different from each other in the eyes of the American healthcare system that is in place. All medical billing specialists need to be thorough about how to process claims in medical billing for patients enrolled in Medicare and Medicaid as well.
Medicare was created way back in 1965 as a Federal healthcare program specifically for citizens over 65 years of age, though people below 65 with certain disabilities are also eligible. There is no asset or income limit for eligibility and people with a work history will automatically become eligible on attaining 65 years of age. Medicare comprises four parts, of which Part A is meant for in-patient care, hospice care, or an inpatient care at any nursing facility for limited periods soon after prolonged hospital stay.
Whereas, Part B is defined as “medical insurance” and covers doctors’ visits, medical equipment, lab and X-ray services and certain outpatient services ( including home health care). Most of the seniors would automatically qualify for Part A coverage free of cost, depending on their work history, or that of their spouse’s. In order to qualify for Part B coverage, a monthly premium needs to be paid, which is deducted from the Social Security benefit. Part A and B together are referred to as fee-for-service, also known as “traditional” or “original” service. Patients have the liberty to choose any doctor who is willing to accept Medicare. Only a portion of the cost is paid by patients, though “traditional” Medicare does not cover all of one’s health needs, the exceptions being dental fees and payment for eyeglasses.
Part C of Medicare is also referred to as “Medicare Advantage”, which went under the nomenclature Medicare + Choice earlier. The program is designed to offer coverage through several private insurance companies. The plans offered have varied cost structures, including benefit packages that are different from fee-for-service Medicare. The latest addition to the Medicare range is Part D, which covers prescription drugs. There are several private plans that are sponsored by drug insurance companies, from which beneficiaries may choose the one that best suits them. However, one needs to go through all plans to learn if the required drugs are covered.
Medicaid has always been referred to as the program designed for “the poor”. There is a popular misconception amongst general practitioners that no questions will be asked of them about Medicaid’s coverage. However, Medicaid is a comprehensive program that offers insurance coverage to over 50 million people, which is probably why Medicaid is the single largest purchaser – whether it is nursing facility (NF) or long-term care (LTC) in the country. While Medicare pays for just 100 days of nursing facility care, Medicaid takes care of long-term care.
The information required for long-term care in Medicaid includes monthly income, although people without any income need not worry too much, as they still qualify. Those with monthly incomes that fall below the base monthly charges at any NF in the neighborhood will become income-eligible. However there are states that are classified as “medically needy” and some others that are referred to as “income cap”. While clients in the former become income-eligible (provided their income is less than the base charges at the facility) clients of the latter will need to set up “income trusts”. The bottom-line is that income is not a deciding factor as far as eligibility is concerned for Medicaid LTC.
To put it simply, Medicare is for people with a regular source of income, with no limit on either the income or asset. Work history is what is required to qualify for Medicare, though which of the 4 parts one qualifies for needs to be decided. With Medicaid, the benefit is that it is meant for people without any source of income, or with incomes that are less than the base monthly charges at the nearest nursing facility.
ACA / HIPAA / Reforms