An Overview Of Medicare And Medicaid

Medicare and Medicaid are the governmental health insurance programs for vulnerable communities of America. Medicaid is run by the central government and state government to provide healthcare facilities to low-income people, while Medicare is purely funded by the government to provide coverage to people over 65 years old or having disabilities regardless of income level. If a person is eligible for both programs, there is no restriction, and one can have both. There are differences in cost-sharing and services. Medicaid covers outpatient and inpatient hospital facilities, pediatric facilities, mental health facilities, prescription drug costs, dental healthcare, work-related and speech treatment, physical rehabilitation, family planning care services, and many other services that vary from one state to another. The eligibility criteria for qualifying for Medicaid also vary in different states. The medical billing specialists understand the criteria of Medicaid suitability in the respective state. The endorsed Medicaid website provides all the details about the plan.

The Medicare program was created in 1965 to assist younger people who have disabilities to have access to the eminence healthcare services. It is managed by “The Centers for Medicare and Medicaid Services (CMS)”, and processes the claims of Medicare. It is basically divided into various parts, and each of these parts covers specific health services.

Part A is the pathologically needed services to cover hospital care, expert nursing care, clinical care, and nursing home care.

Part B is Preventive Care, which includes certain preventative healthcare facilities, for example, outpatient and inpatient mental health, ambulance services, and clinical exploration.

Part C is the Medicare Advantage Plan that covers the services provided by hospitals or private healthcare centres. Part D is prescription drugs, including all the costs of drugs that are waged on a monthly basis. All the details of services covered by the Medicare program are mentioned on the official page of Medicare (Carlo et al., 2019).

The System of Medicare works on the basis of single-payer and makes payments to the insurance firms in the best interests of the individuals who are signing up for this program. The medical billing representatives submit claims to MACs to process afterwards when an individual receives medical services covered by the respected Medicare plan. The billing specialist is responsible for inputting all the information from the providers into the medical billing software. It includes information provided by the patient enrolled with the Medicare program, regarding all the expenses of the services he or she got in the hospital. There are certain codes of each service and the prices of each service are already negotiated with the hospitals and input in the software. This information is put in the medical billing software and provided print of the bill to the patient, or the claim is submitted via mail. The medical bill is submitted with the medical codes similar to the codes of Medicaid, such as CPT and ICD-9-CM, and the service codes are also placed. There are four different parts of Medicare services, and for filing claims, it is necessary for a billing specialist to understand these codes.

The claims associated with Part A will be processed by the medical billing expert in collaboration with clinics and clinics which suggestion inpatient healthcare. The Claim in Part A will be filed in the best interests of the claimant via the UB-04 form, which is also called the “CMS-1450 form”. The Part B claims are filed in the “CMS-1500 form” which is used for typical claim form which is used by the service providers to the Medicare billing carriers. These forms should be obtained from other sources such as NUCC who are responsible for updating and maintaining these forms. Parts C and D should be filed independently. All the claims that are related to Part C and Part D of the Medicare program are covered by the private insurer, which is not filed through Medicare. The private insurers have an agreement with Medicare, so these claims are not supposed to be filed by the claimants. Medicare pays a certain amount per member to private insurers every month. However, some drugs are not covered in the Part D plan.

According to Kivlahan et al. (2016), the amount is reimbursed by Medicare to the hospitals and physicians for the services they provide to the beneficiaries of Medicare. The rates of reimbursement are set by Medicare, which is less than the amount that a private insurance company pays to the hospitals. The hospitals are agreed to accept the rates of Medicare are the panel hospitals for the Medicare beneficiaries. Due to the lower rates many physicians don’t opt to sign a contract to accept Medicare reimbursement as a payment for their services, some physicians partially accept Medicare reimbursement for their limited procedures. When patients receive medical services from nonparticipating providers, they may pay their bills and seek reimbursement for the portion that is covered by the plan.

The Affordable Care Act (ACA) covers many provisions of the Medicare program, and more than 57 million disabled and seniors who are relied on Medicare for their healthcare coverage. ACA has minimized updates in Medicare payment levels to health care units, hospices, and other health care providers. It also reduced “Disproportionate Share Hospital (DSH)” payments to compensate health facilities for the services they provide to uninsured and low-income patients. ACA has covered provisions to improve the benefits of Medicare by providing some preventive benefits for free, for instance, a free screening of cardiovascular diseases, diabetes, colorectal and breast cancer, and closing the coverage gap. ACA is also working on the establishment of new sources of revenue to strengthen the Medicare program. ACA is playing a vital role in strengthening the financial status of Medicare in the future while offsetting some costs and providing additional services to the people enrolled with Medicare.

ACA also covers the Medicaid program, and it has supported Medicaid to increase the enrollment of adults and children who were not eligible for Medicaid in the past. This resulted in enrollment growth, and also Medicaid coverage has expanded. As a result, the uninsured rate has reduced in many states. The expansion of Medicaid has improved access to care and raised the use of utilization of healthcare services among the poor population of the country. ACA plays an important role in improving the health of the low-income population. The expansion of Medicaid under ACA has positive impacts on the coverage and access to quality health care and improves the health of vulnerable communities.

Both of these programs are highly beneficial for people who cannot afford quality healthcare services. Medicare covers senior citizens and disabled people to provide them with health facilities. The Medicaid program covers needy communities of all ages, sexes, and races in the USA. To improve Medicare and Medicare services, there are certain recommendations. First, they should assist people in picking the right plans for them. Secondly, to rethink and redesign the benefits to improve medication and reduce health disparities. Policymakers should acknowledge that patient care can be improved by the use of the latest medical technologies. Innovations in products and services are required. New models are required to cover other vulnerable communities that are not qualifying the standards set by Medicare and Medicaid programs.

References

Carlo, A. D., Baden, A. C., McCarty, R. L., & Ratzliff, A. D. (2019). Early Health System Experiences with Collaborative Care (CoCM) Billing Codes: a Qualitative Study of Leadership and Support Staff. Journal of General Internal Medicine, 34(10), 2150-2158.

Kivlahan, C., Orlowski, J. M., Pearce, J., Walradt, J., Baker, M., & Kirch, D. G. (2016). Taking risk: early results from teaching hospitals’ participation in the Center for Medicare and Medicaid Innovation bundled payments for a care improvement initiative. Academic Medicine, 91(7), 936-942.