Medicare & Medicaid: Comparitive Analysis

Introduction. Medicare Parts A (Hospital Insurance): Eligibility

Part A premium-free covers

• People aged 65 years or older
• A patient paid Medicare taxes for a minimum of 10 years when working (Grabowski et al., 2017)
• Must be enrolled for part B

However, one is eligible for the cover without paying premiums if they receive retirement benefits from social security or from Railway Retirement Board.

Medicare Parts A (Hospital Insurance): Covers

Services covered:

• Inpatient care in the hospital and Hospice care for the terminally ill patients
• Home health care as the doctor’s order and the hospital accepts
• Nursing home care (inpatient care in skilled nursing facilities that’s not custodial or long-term care) (Graham et al. 2018)

Services not covered:

• Long-Term Care (also called custodial care) (Grabowski et al., 2017)
• Most dental care and eye exams related to prescribing glasses
• Cosmetic surgery and Acupuncture
• Hearing aids and exams for fitting them

Medicare Parts B (Health Insurance): Eligibility

To be eligible for Part B one must either be:

• 65 years old
• Have a disability
• Have end stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) (Leifheit et al., 2018)

Generally, Part B covers:

• Clinical research
• Ambulance services
• Durable medical equipment (DME)
• Mental health

Medicare Parts B (Health Insurance): Covers

• Inpatient and Outpatient services
• Partial hospitalization
• Limited outpatient prescription drugs

However, it does not cover:

1. Most dental care and eye exams related to prescribing glasses (Graham et al. 2018)
2. Dentures and Cosmetic surgery
3. Acupuncture
4. Hearing aids and exams for fitting them
5. Routine foot care

Medicare Parts C (Medicare Advantage): Eligibility and Coverage

Eligible citizens must be registered for Medicare part A and B (Grabowski et al., 2017).

Part C covers:

• Hospital and medical services
• Prescription drugs
• Dental, vision, and hearing services
• Additional services, such as fitness memberships (Leifheit et al., 2018)

Medicare Parts D: Eligibility and Coverage

For one to be eligible:

1. They must be enrolled in original Medicare cover (Leifheit et al., 2018)
2. Medicare Part D covers add-on prescription drugs.

Add-on prescriptions include:

• HIV/AIDS treatments.
• Antidepressants and Antipsychotic medications (Leifheit et al., 2018).
• Anticonvulsive treatments for seizure disorders.
• Immunosuppressant drugs.
• Anticancer drugs (unless covered by Part B) (Leifheit et al., 2018)

Medigap and supplement insurance

1. It is an add-on option
2. Eligible for original Medicare members (Leifheit et al., 2018)
3. One must not have subscribed for Part C
4. Used for covering Medicare costs
5. Medicare costs include premiums, deductibles, and co-pays.

Medical Necessity

These are essential medical services. They are provided by a registered healthcare provider. These services aim at establish right treatments

They include:

• Evaluating, diagnosing, or treating an illness
• Treating an injury, disease, or its symptoms.

Limiting charges

1. A limit set by law for the amount of a doctor can charge a Medicare patient
2. This laws applies to doctor who do not accept Medicare insurance
3. It also limits doctor who accepts Medicare partial payment
4. The amount is set at 15% more than Medicare amount (Grabowski et al., 2017)
5. The limit differs in various states. (Graham et al. 2018)
6. Some states limit further.

Process of patient registration

1. Registration is by filling a form.
2. A patient should write their basic personal information
3. The patient should sign the form or provide thumb impression (Graham et al. 2018)
4. The details are fed to the HIS registration module system
5. A unique identification number (UIN) is generated
6. The patient is provide with a printed UIN containing, name, address and date of birth (Grabowski et al., 2017)
7. Application fee is collected and receipt issued

Medicaid guidelines and eligible groups

Medicaid covers the under-privileged. To qualify for Medicaid, one must be a citizen of the state in question, and be financially handicapped and medically needy.

Eligible groups include:

• Low-income families
• Qualified pregnant women and children
• Individuals receiving Supplemental Security Income (SSI) (Grabowski et al., 2017)

Medi-Medi (Medicare and Medicaid)

• Laws about Medicaid eligibility differ in various states.
• In some states, one must be enrolled in Medicare to qualify for Medicaid (Graham et al. 2018)
• Medi-Medi covers most health concerns
• Medi-Medi is complementary when covering;
• Nursing home care, personal care, and home- and community-based services
• Medi-Medi members automatically receive Medicare Part D.

Medicaid verification

1. Medicaid Eligibility Verification System (MEVS) verifies if applicants are eligible (Graham et al. 2018)
2. The electric system provides data specific verification
3. It helps to reduce claim denials
4. It also aims at eliminate Medicaid fraud
5. The service can be accessed 24/7
6. MEVs provide Mediacid with updated and easy access to eligibility information

References

Grabowski, D. C., Joyce, N. R., McGuire, T. G., & Frank, R. G. (2017). Passive enrollment of dual-eligible beneficiaries into Medicare and Medicaid managed care has not met expectations. Health Affairs, 36(5), 846-854.

Graham, C. L., Stewart, H. C., Kurtovich, E., & Liu, P. J. (2018). Integration of Medicare and Medicaid for dually eligible beneficiaries: A focus group study examining beneficiaries’ early experiences in California’s dual financial alignment demonstration. Disability and health journal, 11(1), 130-138. Web.

Leifheit, E. C., Wang, Y., Howard, G., Howard, V. J., Goldstein, L. B., Brott, T. G., & Lichtman, J. H. (2018). Outcomes after carotid endarterectomy among elderly dual Medicare-Medicaid–eligible patients. Neurology, 91(17), e1553-e1558. Web.