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Health Care, Medical

Medicaid and Medicare

Medicaid and Medicare are government programs that aim at providing healthcare to marginalized groups like the elderly and the disabled. Medicaid and Medicare seem different but both fall under the same federal department and that is the Centre for Medicare and Medicaid Services. Medicare is an insurance program that is aimed at covering the elderly and the disabled so as to help them in accessing medical care. More than 44 million people are currently enrolled in the program and it costs the United States an average of $432 billion annually. Medicaid, on the other hand, serves the elderly people and the special groups who cannot be able to pay for insurance covers or cash to access health care services. More than 40 million people are enrolled in the program currently and $330 million is spent annually to finance the program. This paper will give a description of what is considered to make one legible for Medicare and/or Medicaid benefits and how the current qualifications can be modified to serve more people. The paper will also discuss the process followed by the Medicare program to reimburse the costs to the health facilities and insurance companies that cover the cost. Finally, the effects of the affordable care act to the programs will be discussed.

Qualification for Medicare and Medicaid benefits

The qualification for the eligibility to get access to Medicaid is set by each state independently. Other than the fact that the program is geared toward helping those who earn low incomes access quality healthcare, there are other qualifications a person should meet to be eligible. These qualities include marital status, disability status, other assets, citizenship, and age. Qualifications include, being below six years and a family income is less than 133 percent of the Federal Poverty Level (FPL), and expectant mothers who fall below the poverty line. And finally, young adults under 19 years who come from families that are below the poverty line (Centers for Medicare and Medicaid Services, 2013).

On the other hand, Medicare is medical insurance that covers American citizens and takes care of the bills in case one gets sick. It targets elderly people and disabled groups that need constant medical care. The program consists of two parts that are part A and part B. But recently, other two parts were included in the program that is C and D. A help pay the bills due to staying in the hospital. These bills include the cost of food, supplies, laboratory testing and being offered a semi-private room by the healthcare facility. Part A also covers costs that arise when a patient is cared at home and for specific medical equipment such as walkers and wheelchairs for the aged and disabled persons. This cover is available without paying any premiums. Part B helps in paying the costs due to medical checkups for the elderly and medical care at home for the aged people. This is covered by payment of premiums of $96.40. Part C gives the people subscribed to the cover the opportunity to choose a customized cover that suits their condition (Centers for Medicare & Medicaid Services, 2014). And finally, part D covers prescription drugs. It requires that users pay premiums and also a deductible

For one to be eligible for Medicare, he or she must either be 65 years or have total kidney failure that requires frequent dialysis. The disabled also can be covered by the program. Additionally, one must be an American citizen or have been in the country for at least 5 years. This kind of eligibility locks out a lot of people who cannot get access to quality healthcare services. For instance, the qualification that one should be at least 65 years to be eligible for Medicare services is a direct limitation for so many Americans who need that coverage (Barcellos, & Jacobson, 2015). The policy should be changed to accommodate every American who is willing to pay the premiums. This will ensure that every American gets covered. On top of that, the qualification that one must contribute to social security for 10 years is too long. So long as somebody is a Citizen of the United States he or she should get covered.

Medicare Billing

The Medicare billing system is set to play as a single-payer for the healthcare services to the insurance companies instead of the American citizens. This is as per the program a person is enrolled in. the medical billing officials from the healthcare facilities file a claim to the MCAs for processing after the hospital has offered medical services to a person according to their medical plan. The medical billing officer inputs the information from the healthcare provider’s super bill into medical software that is compatible with the billing system. This includes the name of the facility, the name and information about the patient, the treatment information, and any medical codes that are relevant to billing. Then a CMS-1500 claim form will be printed and submitted to Medicare Administrative Contractors (MAC) for processing (Barcellos, & Jacobson, 2015).

For part A, the medical billing official will file the UB-04 form on behalf of the healthcare provider in hard copy for billing. This is the only hard copy accepted by the CMS from hospitals or skilled nursing facilities. For part B, Form CMS-1500 will be used in filing a claim. The form is specified for standard claims by hospitals. Part C and D use a private insurance company and thus claims cannot be relayed through the Medicare billing system (Sommers, Kenney, & Epstein, 2014). This is because private insurers have an agreement to receive a certain amount per member who subscribes and uses this program. This makes the claims in part C and D be treated the same way as a normal claim.

The Impacts of the Affordable Care Act (ACA) on Medicare and Medicaid Recipients.

The ACA has brought a significant impact on the running and the recipients of Medicaid and Medicare programs. For instance, the new data from the Centre for Medicare and Medicaid Services (CMS) shows that the rate at which people are enrolling to be members of the Medicaid program had increased by 4.8 million people. This is due to the open enrollment provided by the Affordable Care Act since October 2013. The ACA also has led to the Medicaid expanding its coverage to low-income earning adults thus covering more Americans than before. Overall, the data suggest that the Affordable Care Act is having a direct positive effect on the enrolment rate into Medicaid, particularly in states that have implemented the expansion of Medicaid (Barcellos, & Jacobson, 2015).

In addition to that, the ACA has led to the expansion to cover low-income adults. The ACA expanded the eligibility to access Medicaid services to those people whose incomes are at or below the poverty line as per the provisions of the federal government of the United States. In the past, Medicaid only covered children who came from poor families, expectant mothers, aged people, and those living with a disability. The low-income earners were excluded. The ACA also modernized the enrolment process thus making it simpler and easy than before. This made it possible for many people to understand the whole process thus increasing the enrolment rate exponentially (Terp, 2014). Finally, it increased the outreach and enrollment efforts. The ACA spurred the outreach campaigns that helped connect with more eligible people to be covered by the programs. This encouraged individuals to enroll and thus covered as many Americans as possible.

Conclusively, the Medicaid and Medicare programs have helped the American people get access to quality healthcare at a relatively cheaper cost. But the eligibility has been limited to only a few people and left alt more out. But since the dawn of the Affordable care act, eligibility has been broadened and more people are eligible to be enrolled in Medicare and Medicaid programs. The ACA has increased the enrollment rate and also the outreach efforts that have in turn increased the number of Americans who are covered. This means that the United States is able to ensure a healthy population and thus an increase in the rate of economic development.


Barcellos, S. H., & Jacobson, M. (2015). The effects of Medicare on medical expenditure risk and financial strain. American Economic Journal: Economic Policy7(4), 41-70.

Centers for Medicare & Medicaid Services. (2014). Medicaid eligibility. Available from URL: http://cms. hhs. Gov/Medicaid/eligibility/criteria. Asp.

Centers for Medicare and Medicaid Services. (2013). Medicare Claims Processing Manual, Chapter 6—SNF Inpatient Part A Billing and SNF Consolidated Billing.

Frean, M., Gruber, J., & Sommers, B. D. (2017). Premium subsidies, the mandate, and Medicaid expansion: Coverage effects of the Affordable Care Act. Journal of Health Economics53, 72-86.

Sommers, B. D., Kenney, G. M., & Epstein, A. M. (2014). New evidence on the Affordable Care Act: coverage impacts of early Medicaid expansions. Health Affairs33(1), 78-87.

Terp, S., Desai, A., Tang, C., Monks, K., Sirody, J., Boyajian, S & Menchine, M. (2014). Evaluating Knowledge of the Affordable Care Act and Likelihood of Qualification for Medicaid Expansion among Uninsured Ed Patients at Los Angeles’s Largest Safety-net Hospital. Academic Emergency Medicine21, S142.



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