Medicaid and Medicare are both government-operated programs funded by different parts of the government, and preliminarily serve different groups in society. Medicaid is a federal healthcare assistance program serving low-income individuals of every age. The patient pays no part of the involved cost covering the medical expenses. The operation of Medicaid is by the state and the local governments under the federal guidelines. Medicare is a federal health insurance program where the coverage of the individual medical bills is through trust funds. It assists individuals over 65 years, dialysis patients, and younger disabled people. Medicare is universal in America in every state-operated through the Centers for Medicare and Medicaid Services. The purpose of this essay is to elucidate on the descriptions and operations within Medicare and Medicaid.
Description of the Qualifications to Receive Medicare and Medicaid
There are different required qualifications to receive Medicare or Medicaid services as the initial authorization and granting of Medicaid services depends on the written application through a State-prescribed form . The granting of Medicaid is upon the determination of eligibility based on a written request made by an applicant or an authorized applicant. Granting of Medicaid services is also focus upon the redetermination and renewal of the recipient’s eligibility. In the case of Medicare, there is a 65 years old rule to qualify for its benefits and having American citizenship, the applicant or the applicant’s spouse has worked in America and being a government employee(Klemm, 2000). An individual needs to have a permanent legal resident living in America for five years to qualify for Medicare services. It requires those eligible for the Social Security or railroad retirement benefits, having earned over 40 credits for a decade, even without getting the benefits. There is a guarantee for individuals earning 40 credits in the payroll taxes while working on not paying premiums for Part A benefits of Medicare services covering the inpatient hospital care. There is no need to work for the qualification of Part B services that focus on the doctor’s services and outpatient care or Part D prescription coverage. An individual can also qualify for Part A premium-free benefits on the spouse’s work records if only the spouse and the partner are 62 and 65 years old, respectively.
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The Modification of Medicare Qualification to Serve More People Considered a Vulnerable Population
The modification for the eligibility and the available services is necessary to improve the quality of Medicare for the vulnerable population. The vulnerable population in the society has problems accessing quality health care services, increasing their burden of poor health, which needs immediate improvement for equality. The recommendations for such improvements include providing additional investment for developing, evaluating, and supporting the healthcare delivery models to meet particular requirements of the vulnerable population. The government should focus on the provision of the universal qualification models for every patient in need of Medicare services to enhance the quality of health care. The Medicare eligibility criteria need to incorporate the payments of health plans to promote the provision of quality and improved health care services for all the patients in the society, including the vulnerable population (Moon, 2018). There should be dual eligibility for chronic conditions by the federal government for every Medicare per-beneficiary expenditure having multiple chronic conditions. There should be consistency in the functional and social needs relating to the provision of Medicare and Medicaid services to enhance the quality delivery of healthcare services. The covering of home modification and mental health care is necessary for the improvement of the quality of healthcare services, including initiation of health assessment, looking at medical problems and operations. Another requirement needed is the revision of the Medicare and Medicaid eligibility system to incorporate a balanced medical assistance program that includes everyone in need, such as the vulnerable population.
How Medicare Affect the Medical Billing
The Medicare health care program is a government-initiated program operating under the jurisdictions of the state and federal government instead of the health insurance organizations. Medicare has special techniques for processing medical claims related to the programs. The perfect knowledge of the Medicare program enhances fair and proper medical billing for patients. The medial billing involves inputting information from the healthcare provider’s super-bill into compatible medical billing software. It includes the information of the patient and the provider regarding treatments patients receive and the relevant medical codes and costs. Medicare influences medical billing in diverse methods such as the submission of the necessary MACs for processing after reception of Medicare plan by an individual.
The MACs include the entire related patient’s information related to the treatment they have received, costs, and the related medical codes. After filing claims related to Medicare, an individual requires to input medical codes identical to the ones the patient is planning to use for the Medicaid services. The Medicare affect medical billing through the association of various medical coverage schemes such as Part A medical necessary services, Part B preventive care filing, Part C and D medical schemes, separately. The medical billing specialists pass the Medical claims filed by an individual on behalf of the provider sent directly to the MACs for processing. The claim takes one month for processing by MACs. Part A claims directly remit funds to the provider making any extra deductible fees in Medicare authorized by the patient. Part B claims remit the healthcare funds either to the patient of the provider for the care covered through the plan. Medicare pays 80 percent of the approved amount in medical billing if the provider accepts the assignment of the claim. The provider receives the remaining 20 percent by the patient and if the provider doesn’t accept the assignment of the claim, the Medicare on approval caters for it.
A Brief Definition of the Qualifications for Medicare and Medicaid Benefits
The Medicaid and Medicare qualifications and benefits for each beneficiary depends on the government initiated domains regulating the entire process. There are rules associated with the system such as a 65 years old rule to qualify for Medicare benefits and having American citizenship, the applicant or the applicant’s spouse has worked in America and being a government employee. An individual requires a permanent legal resident living in America for five years to qualify for Medicare services. It requires those eligible for the Social Security or railroad retirement benefits having earned over 40 credits for a decade even without getting the benefits. There is a guarantee for individuals earning 40 credits in the payroll taxes while working on not paying premiums for Part A benefits of Medicare services covering the inpatient hospital care. The Medicaid application is suitable for the applicant requiring long-term medical or nursing home care.
The Description of the Impact That the ACA Has Had On Medicare and Medicaid Recipients
The Patient Protection and Affordable Care Act (ACA) is revolutionizing the health insurance sector in diverse perspectives with massive influences. It helps in lowering the prescription drug cost for Medicare beneficiaries while expanding the Medicare preventive benefits. The major influence of the system on the Medicare and Medicaid Services is affecting the rising premiums, out-of-pocket costs, deductibles with plans sold on the health insurance exchanges (Alcalá et al , 2017). Other impacts of the ACA to the healthcare programs include the preventive medicine provisions incentive accountable care and the individual mandates affecting the healthcare insurance.
References
Alcalá, H. E., Chen, J., Langellier, B. A., Roby, D. H., & Ortega, A. N. (2017). Impact of the Affordable Care Act on health care access and utilization among Latinos. The Journal of the American Board of Family Medicine , 30 (1), 52-62.
Klemm, J. D. (2000). Medicaid spending: A brief history. Health Care Financing Review , 22 (1), 105.
Moon, M. (2018). Medicare Now and in the Future . Routledge.
