Medicare and Medicaid are federally funded social programs established in 1965. For the past 50 years, Medicare and Medicaid have played crucial roles in protecting the health and well-being of vulnerable Americans. Medicare and Medicaid started as primary insurance for those who did not have health insurance, but they have evolved over the years. The two programs now play a significant role in the American health care system.
Qualifications to receive Medicare and Medicaid
Medicare and Medicaid are two different programs; thus, there are different qualifications for each program. Medicare is available for most U.S. citizens and permanent legal residents over the age of 65. Individuals under the age of 65 are not eligible for Medicare unless they have received more than 24 months of Social Security disability benefits, have permanent kidney failure, and require routine dialysis or a kidney transplant (Antonisse et al., 2017). Individuals with amyotrophic lateral sclerosis (ALS) are also eligible for Medicare. Medicare is classified into Part A, Part B, Part C, and Part D. For instance, an individual is qualified for Medicare Part A if the individual or the spouse worked for at least ten years and paid Medicare payroll taxes. Medicare Part B has a premium that recipients have to pay, whereas Part C and Part D have additional benefits that the beneficiaries are also required to pay.
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Alternatively, Medicaid is a joint state and federally funded program to support low-income individuals and families to cover medical and long-term custodial care for those who qualify. Some Medicaid benefits, such as inpatient and outpatient care, overlap with some of the Medicare benefits (Johnston & Joynt, 2019). Medicaid’s eligibility is strictly income-based, and it varies from state to state. In New York, one qualifies for Medicaid when his/her income does not exceed 138% of the federal poverty level (FPL). Infants and pregnant women whose income do not exceed 218% of the FPL also qualify for Medicaid. A single elderly or a disabled person is eligible for Medicaid in New York if the individual earns less than $825 per month and has less than $14,850 in total assets. In Alabama, one qualifies for Medicaid if his income does not exceed 146% of the FPL. Therefore, a family of one should not earn more than $1,520, and a family of two should not earn more than $2,058 (Jia et al., 2014). Like Medicare, Medicaid is only available for American citizens and permanent and legal residents. There are different Medicaid benefits for children, parents and caregivers, pregnant women, and the elderly.
How can this be modified to serve more people who are considered a vulnerable population?
According to the Center for Medical Services (CMS) statistics, 56.8 million Americans were receiving Medicare benefits in 2016. Out of the total beneficiaries, 47.8 million beneficiaries qualified for Medicare because of their age, while 9 million qualified because of disability (CMS, 2019). On the other hand, approximately 74 million people were under the Medicaid program in 2017 (CMS, 2019). 40% of the Medicaid enrollees are children, and the rest are adults, disabled, and aging people. People with disability make up 15% of Medicaid beneficiaries. California, New York, Texas, and Pennsylvania have the highest recipients. Currently, 8.3 million enrollees have dual membership for Medicaid and Medicaid.
While the two programs are helping millions of Americas, many vulnerable people are left out. There is a need to expand the program by adjusting the requirements to include more vulnerable Americans. According to a report by the Kaiser Family Foundation, there are 27 million uninsured Americans in 2017 (Antonisse et al., 2017). The number decreased drastically after the implementation of the Affordable Care Act (ACA). As much as ACA expanded coverage, over 27 million Americans remain uninsured because of the high cost of insurance. Most of them are poor adults working blue collar jobs which do not offer health coverage. The Kaiser Family Foundation report adds that people of color are more likely to be uninsured in comparison to non-Hispanic Whites (Antonisse et al., 2017). There is a need to increase Medicaid’s eligibility for non-elderly parents, single adults, children, and pregnant women. Many families are living in poverty who cannot afford insurance, and yet they are left out of the program because their income is above the limit by a small margin.
According to Jia t al. (2014), Medicaid should be expanded such that all Americans below a certain income level qualify for the benefits. Medicaid provides comprehensive and affordable coverage in comparison to other insurance options; therefore, it should be available to all low-income Americans who cannot afford to pay expensive premiums or cost-sharing plans. The government should also streamline Medicaid and Medicare enrollment, as many low-income individuals lack the information that they are qualified. Both programs will serve more vulnerable people if the government increases its funding.
The issue of double insurance should be addressed too. Aforementioned, there are 8.3 million Americans with both Medicare and Medicaid. The system should be streamlined such that individuals benefiting from the Medicare program should not be eligible for the Medicaid program. There is a need to improve the services in each program, such that qualifying American will not have to enroll for both programs. Consequently, there will be more vacancies for some of the vulnerable Americans who have been locked out of the program.
How Medicare affects Medical Billing?
Medicare and Medicaid affect medical billing as medical providers send claims the same way they would do with third-party payers. Billing for Medicare depends on the type of Medicare, which is Part A or Part B. Therefore, the billing process starts when the medical providers send a claim to Medicare, which is processed by a Medicare Administrative Contractor (MAC). MAC evaluates each claim before processing the claim, which takes around 30 days. Health providers follow the same protocol when billing for Medicare Part A and Part B by inputting all the necessary information including patient information, third-party payers, NPI number, procedure codes, diagnosis code, price and plan of service codes (Zheng et al., 2017). The superbill gives all the necessary information which will be used to process the claim. Medicare Parts C and D are complicated as Part C is a private insurance plan such that health providers cannot bill Medicare for the services rendered to patients under Part C coverage. Part D is only available to licensed providers as it covers vaccines and prescription drugs.
There are cases where the provider declines the assignment of the claim, and Medicare will assign the payment to the client. In this case, the patient reimburses the provider for the services. Part A and Part B Medicare have monthly and annual premiums on top of the coinsurance arrangements. CMS is responsible for fixing the deductibles, premiums, co-pays, and coinsurance rates, but they vary greatly depending on patients and procedures. Billing for Medicaid is even harder as Medicaid regulations and billing differ from one state to state. Claim forms and format vary, and the biller has to keep up with the state’s protocols.
Describe the impact that the ACA has had on Medicare and Medicaid recipients
ACA affects Medicare and Medicaid recipients in various ways. The purpose of ACA was to increase coverage for the uninsured and to increase access to healthcare services for the poor and vulnerable. Approximately 20 million uninsured adults gained coverage since the enrolment of the ACA in October 2013. States expanded Medicaid/CHIP enrolment to support ACA, and they witnessed a 36% increase in Medicaid’s enrollees. Surprisingly, there was an increase in Medicaid’s enrollment, even in nonexpansion states as ACA created increased awareness for Medicaid. According to the Kaiser Family Foundation (2018), ACA increased coverage, access to care, affordability, and health outcomes. Medicaid expansion states witnessed significant coverage gains among the low-income population. Increased Medicaid’s membership meant that more vulnerable individuals had access to health services at affordable rates leading to improved outcomes.
ACA addressed the gaps in Medicare concerning preventive and prescription drug benefits. ACA provided room for testing new payment methods to improve the value of care. ACA moved Medicare away from fee-for-service payment to make providers accountable for quality and cost of care. ACA also made significant changes to Medicare Advantage such that payments to Medicare Advantage Plans were restricted until the plans were on the same levels with traditional Medicare. ACA came up with rules to guide the payment and performance of Medicare to improve quality and lower the cost of care for Medicare recipients.
References
Antonisse, L., Garfield, R., Rudowitz, R., & Artiga, S. (2017). The effects of Medicaid expansion under the ACA: Updated findings from a literature review. Kaiser Family Foundation . Retrieved from: https://www.kff.org/medicaid/issue-brief/the-effects-of- medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-march- 2018/
Centers for Medicare & Medicaid Services. (2019). CMS Fast Facts. Retrieved from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and- Reports/CMS-Fast-Facts/index.html
Jia, L., Yuan, B., Huang, F., Lu, Y., Garner, P., & Meng, Q. (2014). Strategies for expanding health insurance coverage in vulnerable populations. Cochrane Database of Systematic Reviews , (11).
Johnston, K. J., & Joynt Maddox, K. E. (2019). The Role Of Social, Cognitive, And Functional Risk Factors In Medicare Spending For Dual And Nondual Enrollees. Health Affairs , 38 (4), 569-576.
Zheng, N. T., Haber, S., Hoover, S., & Feng, Z. (2017). Access to Care for Medicare ‐ Medicaid Dually Eligible Beneficiaries: The Role of State Medicaid Payment Policies. Health services research , 52 (6), 2219-2236.
