While the information below is for those that are looking to receive Medicaid or Medicare it is your job as a medical biller and coder to also know the difference between the two the information covered will include:
1. Patient eligibility
2. Medicaid and Medicare application
3. Medicaid and Medicare benefits
Medicare versus Medicaid: Know the Difference
Patient Eligibility
While many believe that the person must be a low income individual when applying for Medicaid benefits this is not the always the case, having low income is not the only requirement to be approved. The eligibility for Medicaid includes the following:
- People over the age of 65 that are blind or facing another form of disability
- Women who are pregnant and have less than 6 years of age or have income that is below the median income for their county and state
- Individuals that have children living in the home between the ages of 6 and 19 years of age
- Adult individuals that care for children under the age of 18
- Teens that live on their own and are up to 21 years of age
- An individual must receive SSI (Supplemental Security Income)
Patients Eligible for Medicare
The eligibility requirements for Medicare are as followed:
- Muse be a citizen of the United States
- Worked 10 year minimum in a job that has paid money to the Medicare system
- 65 years of age or older (unless disabled or have kidney failure)
There are 3 parts to Medicare:
- Part A- Hospital insurance is provided for those that are on social security and/or retirement benefits from the RRB (Railroad Retirement Board)
- Part B- Medical insurance is provided to those that are also eligible for Part A above this also means that the patient would also have to pay a monthly premium for their insurance.
- Part C- Coverage for Prescription Drugs is provided by private insurance companies where much like Part B the patient has to pay a premium every month
Application
Patients are able to apply for Medicaid from their local Medicaid office or they can apply for Medicaid online depending on the state they currently live in. the application must be completed in full or they can reject or application.
The CMA (Centers for Medicare and Medicaid Services) office administers the application and other services for people that wish to join the Medicare program. If the patient has the requirements mentioned above they are automatically enrolled into the Medicare program. The patients that find them self not meeting the above requirements will have to file form CMS-40B. They can obtain this application from their local SSA (Social Security Administration) office.
The Benefits
The benefits offered by the Medicaid program are very beneficial for families they may be facing financial hardships. The biggest benefit that Medicaid offers patients is the preventive services provided like prenatal care for pregnant women, immunizations and even emergency services.
The benefits Medicare are more beneficial for older adults. The daily expenses they face for hospitalizations and prescriptions are all conveniently managed through Medicare benefits.
Dealing with Medicaid and Medicare as a Medical Billing Specialist
As a medical billing specialist you will have to work with patients that are on Medicaid and Medicare. When filing the claims paperwork under primary health plan it should have Medicaid listed there and under secondary health plan Medicare should be listed if applicable. You will then visit the Medicaid website; they should have a section on their website that specifically applies to providers. If the patient is visiting for an emergency service you will be able to view what services are covered under their particular health plan. Once it has been verified you will then add the patients Medicaid ID and lower the amount and file the information on all of the patient’s accounts. For many Medicaid cases if the information is unable to be verified on your end then the patient will have to contact the either Medicaid directly or the hospitals inpatient or their outpatient office and get the correct Medicaid number and then have them call you back with the correct information.
