Comparison of Medicare and Medicaid – Health System Example

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"Comparison of Medicare and Medicaid" is a worthy example of a paper on the health system. The funds to support Medicare comes from two trust fund accounts held by the U. S that is medical insurance fund trust and supplementary medical insurance trust fund. For Medicaid, its support funds come from federal medical assistance percentage where the state receives percentage expenditure based on per capita income of the state and direct state payment. Medicare which is a social insurance program is administered united States of America federal government while Medicaid which is an assistance program is governed by each specific state in the united state of America (Conway and Berwick, 2011). Medicare Eligibility requirement Over 65 years of age or older and Gets social security retirement benefits Not getting social security retirement benefits but have worked in federal, state or local government to be insured.   If you are under 65 you are eligible if you Get Social Security disability benefits Have worked for a long time in state and federal and qualified for social security program for disabled   If You Have Kidney Failure and receives maintenance for dialysis and transplant or             You are insured or are getting social security benefits monthly.

            Rendered service long enough in government to be insured for Medicare   Differences Midgap is used by people registered in traditional Medicare and not a government-run. Each of the midgap policies is governed by law thus making all the befits the same and the providers charge a different variety of premiums. Medicare Advantage is a combination of several private health plans offered by Medicare as coverage alternative for traditional Medicare covers.   Each plan covers all the benefits covered by traditional programs.   Medicare replacement plan also called Medicare part C which is a combination of parts A and B.

It covers benefits the same way a regular Medicare covers but the difference is the additional benefit where an insurance company may provide a higher percentage.   “ Accepts assignment” means that the doctor or physician agrees to take full compensation amount of the service rendered from Medicare. This effect has much one pays from the pocket since all the expenses are covered with the Medicare services thus meaning no payment is required.   The patient can see a provider that is non-participating and have Medicare reimburse the patient directly.

Medicare compensates claim at 95% of the total amount, while 80% comes from contractors then the patient pay20%. Can Medicare be a primary payer? Federal law and statues prevent Medicare from paying for other services or items expected to form another source within 121 days.   When Medicare is the secondary payer, the main payer must go on and pay primary payment according to the coverage provision. The contract calls for Medicare to pay first therefore, primary may decline to make primary payment.   What time frame does a provider have to file a claim and have it deemed payable?

Are there exceptions? Under the new law for a claim, to be deemed payable should be submitted within one year of the date the service was rendered. But there exist exceptions allowing for the extension of the time limit like administrative errors, retroactive medical entitlement, retroactive medical entitlement involving state medical agencies, and retroactive enrollment from Medicare advantage plan or program of all-inclusive care of the Elderly provider organization. Appeal process levels Redetermination Reconsideration The administrative law judge hearing Appeal council review Judicial review in U. S district court The levels must be followed in the order in order to provide bases for compensation.

Medicaid Eligibility Be age 65 or older Have a permanent disability Be blind Be a U. S. citizen or meet certain immigration rules Be a resident of the state where you apply   Payer of the last choice means that Medicaid always pays last where other insurance is present. Services requiring a Treatment Authorization Request (TAR) Dental services Occupational Therapy Dermatology Therapy   Early Periodic Screening Diagnosis and Treatment Program (EPSDT) and its benefits. It is a health care benefits package that covers all Medicaid registered children aged below 20 years and expectant women.

It provides comprehensive and preventive health care services for children below 21 years of age registered in Medicaid It ensures that children and adolescence receive appropriate preventive, dental, mental health and developmental services. Time frame a provider required to file a claim and have it deemed payable. Straight Medicaid claims bust be filed within 12 months of the date of service while KIDMED claims should be filed 60 days after rendering the service. There is no responsive exception to the filling of the claim deadline (Bindma et al, 2012).   How often are updated benefits/ eligibility cards sent to the recipients?

Once one is approved for Medicaid he/she receives a Medicaid identification card via mail once a year. What are common reasons for claim denials for “ medically unnecessary” and how does this affect the patient paying out of pocket for both Medicare and Medicaid recipients. Provider error Medical necessity denial Provider not enrolled in Medicare Medicare secondary payer Contractor error This results in patients overspending their saving thus incurring shortage or lack of basic medical supplies.


Conway, H.P. and Berwick,M.D. (2011). Improving the rules for hospital participation in Medicare and Medicaid. Journal of American medical association. 306(20)2257-2257

Bindman, B.A., Blum, J.D. and Kronick,R. (2012). Medicare Transitional Care Payment, a Step toward the Medical Home. New England journal of medicine. 13(368)692-694

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