Difference between Medicare and Medicaid
Medicare and Medicaid fall under the jurisdiction of the U.S. Department of Health and Human Services and follow the federal guidelines but remember that there is no national Medicaid program. Medicaid is a joint federal and state program that helps people with limited resources and income. It follows general rules the federal government has imposed but each state varies on how they run its own Medicaid program. It offers coverage for services like nursing home care facilities and personal care services which Medicare does not cover.
Medicare provides insurance for people over 65 years old and people under 65 with certain conditions or disabilities. The Centers for Medicare and Medicaid Services governs Medicare and is considered a federal program. Because of this, standard coverage for cost is implemented for all individuals and unlike Medicaid, the coverage will be the same for all regardless of the state in which the patient resides.
Medicaid Eligibility
Candidates for Medicaid Program are usually those who come from low-income families and individuals. It is still a form of insurance therefore no actual money is handed to the patients eligible rather, the provider is billed directly. Copayments are also possible for some medical services not covered.
A. Pregnant Women. Medicaid will cover both the child and the mother regardless of marital status.
B. Children and Teenagers. The parents may apply for a Medicaid program for their child who is 18 years old and younger if their income is limited and if the child is sick enough to need nursing care but could stay enough at home with provided good quality care. Teenagers may apply for a Medicaid program on their behalf or by any adult.
C. Blind, Aged, and/or Disabled. People above 65 years old, blind, and disabled with limited resources may apply for Medicaid. Terminally ill patients in need of hospice services may also apply. Aged, blind, and disabled people requiring nursing home care but can stay at the special community for services may also apply.
Medicare Contractors and working with them
Medicare and Medicaid are both under the CMS which is an organization that medical coders and billers work with. Dealing with them directly is through the local contractors and the ones the coders should think about whenever they submit their claims. Each Medicare contractor performs the following:
1. Receive electronic claim submission
2. Follow the same filing time requirements set by Medicare itself
3. Pay according to Medicare fee schedules and timely payment rules
4. Observe HIPAA in their communications and follow its regulations
5. Maintain a phone line with an interactive voice response
All contractors work the same way and the steps being followed across them which are:
1. Supply the provider’s PTAN (Provider Transaction Access Number), the NPI (National Provider Identification Number), and the last 5 digits of the TIN (Tax Identification Number).
2. Supply the patient’s Medicare number, name, and date of birth before any privileged information will be shared
After you have given the details necessary, you may then make your claim or inquiries that are specific to certain patients. This can be done through a phone call and will allow Medicare to function more efficiently for a large number of claims that they receive daily.
Each Medicare contractor has representatives that are available to assist the medical coders when they are not sure about something in the claim being submitted however, they are not allowed to advise on what to code and what to bill. They can only direct them to the correct path that will make their claim payable. The same information as mentioned above is needed with the additional date of birth of the patient, service date, and billed amount of the claim in question.
Plan Differences in Medicare
Medicare pays off only 80% of the allowed amount after the patient meets the annual deductible. The remaining 20% is held responsible by the patient, who can enroll in a Medicare-approved supplemental plan to cover the remaining 20%. These supplemental plans are the Medicare Part C Plans which are Medicare-approved plans by the commercial insurance companies that sponsor Medicare and sometimes pay differently than the standard Medicare plans. Medicare replacement plans may cover 100% of the allowed amount once a copay deductible has been met.
What is a Medicare Plan C Plan?
Also called a Medicare Advantage Plan, it serves like an HMO or PPO that a patient may add to be a part of his Medicare plan. MA Plans are offered by private insurance companies approved by Medicare. They offer extra coverages such as vision, dental, and/or hearing programs, and joining these plans will provide all of the Part A hospital Insurance and Part B medical insurance coverage. Healthcare providers should be under the plan’s network for this to work out.
The front desk staff must be able to know the difference between a commercial insurance plan and a Medicare Part C replacement plan especially if they are sponsored by the same insurance company because the coding for these is based on the distinction between these two. If the provider does not have a specific Part C contract with the carrier, then Medicare’s reimbursement policy will be followed for the processing of claims.
References: What is the Medicaid program? | HHS.gov | What’s the difference between Medicare and Medicaid? | HHS.gov | Medicare Advantage Plans | Medicare