Understanding Medicare and Medicaid- A Comparative Analysis of Reimbursement Structures

Understanding Medicare and Medicaid- A Comparative Analysis of Reimbursement Structures

Medicare is a health insurance program for American citizens who are sixty-five years old or above. It also covers people who are younger but living with a disability. It was started in 1965, and it has so far benefitted millions of United States citizens. It covers almost half of the healthcare expenses for the enrolled people. The beneficiaries cover the remaining expenses using other insurance plans or part c or D of the Medicare health plan. The Medicare health insurance plan has four parts. Part A covers inpatient services, B covers outpatient services, D covers self-administered prescription drugs, and C covers managed Medicare. Medicaid is a health assistance program in the United States of America that helps people with limited resources and income. It provides free healthcare to over seventy million low-income earners and pays for half of births in the US and disabled citizens (Miler & Harrington, 1999). It receives funding from both federal and state governments but is managed by the state. Medicaid covers a broad range of health care services, including long-term care services. An individual can be eligible for both Medicare and Medicaid.

The main differences between Medicaid and Medicare include that Medicaid provides help by covering healthcare expenses for low-income individuals while Medicare covers the healthcare expenses for the elderly citizens of America. Medicaid is for all ages, unlike Medicare, which is for the ones above sixty-five years. Medicaid offers personal care and nursing home services, unlike Medicare, which does not offer such services. Medicare is an insurance program, while Medicaid is an assistance program. Medicare is federally managed; hence, the terms are the same in every part of the country. The state government manages Medicaid; hence, it varies from one state to another. It is a federal-state partnership. In Medicare, the members pay part of the healthcare expenses and pay certain premiums monthly. Medicaid co-payment is not a necessity, though it is sometimes needed. The state sets the qualifications for Medicaid, while the Medicare qualifications are being over sixty-five or disabled.

In Medicare, the suppliers or doctor files the claim or bill of an individual’s services. An individual with the Medicare advantage plan does not need to file a claim since Medicare’s insurance companies are paid monthly. The claim should be filed within twelve months after the services are provided; otherwise, Medicare cannot pay. The beneficiary should contact the doctor who provided the services or supplier to file it. If the service provider does not file the claim, there are numbers that the beneficiary can contact (MedPAC, 2005). If the service provider has not filed the claim and the twelve months are almost over, the beneficiary can file the claim. The beneficiary fills out the patient request for medical payment form (CMS-1490S) and fully follows the instructions. The completed form should be submitted together with the bill from the healthcare service provider and a letter explaining why the beneficiary is filing the claim.  Reasons that can lead to the beneficiary filing the claim are the inability of the service provider to submit or the service provider refusing to submit.

In Medicaid, the service provider has to know the billing requirements of the specific state and verify whether the patient is eligible for the Medicaid services. The deadline for submitting the claim varies from state to state and should be observed. When billing, the first step is entering the taxonomy code and provider NPI of the service provider or clinic where the payment should be made (Annett, 2002).  Answer whether the rendering and the billing provider are the same. If they are different, provide the taxonomy code of the rendering provider.  Answer whether the service provided was due to referral. If so, then enter the referring provider NPI. The client information is filled in according to the information on the Medicaid card. No additional information is needed. Please indicate whether the bill is for a child who is being billed under their mother’s ID. Indicate whether the claim is a Medicare crossover. Indicate whether the client has other active insurance policies apart from Medicaid. All the information about the insurance policies should be written down.

References

Annett, M. M. (2002). Billing Medicaid for school-based services. The ASHA Leader, 7(7), 1-25.

Medicare Payment Advisory Commission (US). (2005). Report to the Congress: Issues in a modernized Medicare program. MedPAC.

Miller, N. A., Ramsland, S., & Harrington, C. (1999). Trends and issues in the Medicaid 1915 (c) waiver program. Health Care Financing Review, 20(4), 139.

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Introduction:
Medicare and Medicaid are federal programs that provide healthcare to a large proportion of the US population. The two have similar objectives in providing care, but there are significant differences in them regarding reimbursement.

Understanding Medicare and Medicaid- A Comparative Analysis of Reimbursement Structures

Tasks:
Describe each program, Medicare and Medicaid.
Provide the major features of each program.
Discuss how these programs differ from each other.
Briefly describe the billing process for each program.
Submission Details: