Although they may sound alike and generally serve the same purpose, Medicare and Medicaid are different programs. Agreeably, both programs assist individuals in paying for medical expenses and healthcare but in diverse ways. For instance, Medicare is funded by the Federal government while both the federal and state governments provide the finances for Medicaid. In addition, Medicare is an age-based program where the eligible individuals are above 65 years. Medicaid, on the other hand, targets individuals from low-income families regardless of their age. What this means is that children, adults, as well as the elderly, have equal access to the program. When it comes to Medicaid, federal guidelines do apply, but the rules vary depending on the state. However, income standards are always based on the Federal poverty level (Majaski, 2019). Similar to rules, the coverage benefits vary from state to state. The program generally covers inpatient and outpatient services, transportation to a medical Centre, nursing home care, laboratory services, and custodial care.
On the other hand, the Medicare program comes in four parts. Part A covers hospital care, specifically inside a medical facility, while part B covers doctors and all the necessary medical procedures and equipment. Part D covers prescription drugs, which may be used alongside other private insurance firms. Part C, which is also referred to as Medicare advantage, encapsulates parts A, B, and D. in addition to that, Medicare advantage includes other procedures such as dental, vision, and hearing that may have been omitted by other parts of the program (Smith, 2017). Part A is essentially free since contributions are made to the program throughout an individual's working life. However, for parts B, C, and D, monthly premiums are required as well as other private insurance policies to top up the coverage. For example, in 2020, the monthly premiums for parts B and D are $144.60 and $32.74, respectively (Majaski, 2019).
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The billing procedure for Medicare, which is primary insurance, also follows the different parts. For instance, for parts A and B, the billers follow some protocol, which includes the patient's information like name, NPI numbers, procedure, as well as the codes of diagnosis and place of service (Smith, 2017). For part D, the service provider ought to have a license to the bill, and if not, the total is assigned directly to the patient by the biller. The complexities arise due to the involvement of a private insurance policy. At times, the program may not be able to pay for the service, and in such scenarios, an Advance Beneficiary Notice is given. An ABN contains the item or service that Medicare will not cover, the costs, and the reasons for not paying (Smith, 2017). Nonetheless, there are three options that the beneficiary of the program may choose. The beneficiary may want the service and request Medicare for billing. In contrast, the patient may request for the service and ask Medicare not to be billed. At times, the patient rejects the service after learning of the non-coverage, which means that they are not responsible for payment.
In Medicare, the Federal government also includes and pays private insurance plans to administer the program's benefits. Such plans are implemented through Health Maintenance Organizations (HMOs). Just like the advantage plans of Medicare, HMOs strive for the provision of similar protections and benefits only that they do it with extra costs and different rules. Some of the additional benefits of HMOs include vision and hearing care and are hence secondary plans as they reinforce the Medicare program (Figueroa et al., 2018). When it comes to Medicaid, the rules of billing also change depending on the state. The biller, therefore, has to be updated on the state's rules where the service is being provided. Although Medicaid programs are billed last and hence considered secondary insurance, the specifics are almost the same as those of Medicare as it contains the name of the patient, service provided, NPI, and diagnoses. An ABN cannot be used for Medicaid patients (Smith, 2017).
References
Figueroa, J. F., Lyon, Z., Zhou, X., Grabowski, D. C., & Jha, A. K. (2018). Persistence and Drivers of High-Cost Status Among Dual-Eligible Medicare And Medicaid Beneficiaries: An Observational Study. Annals of Internal Medicine , 169 (8), 528-534.
Majaski, C. (2019, November 25). The difference between medicaid vs. medicare. Retrieved from https://www.investopedia.com/articles/personal-finance/081114/medicaid-vs- medicare.asp
Smith, D. G. (2017). Entitlement Politics: Medicare And Medicaid, 1995-2001 . Routledge.
