Payers Eligibility

Payer Classification & Eligibility

Medicare: Eligibility

• Individuals whose age is 65 years and above.
• Individuals who is suffering from ESRD - End tage Renal Disease.
• Individuals who is permanently disabled or disability for more than 2 years.

Medicare Part A covers:

Inpatient Hospital Care.

Skilled Nursing Facility

Nursing Home

Hospice (End stage Diseased condition)

Home Health Service.

Note: Medicare Part A can be brought by a person less than 65 years of age after paying the premium. It becomes premium free if and have paid FICA (Federal Insurance Contributions Act) taxes or Railroad Retirement taxes and gained 40 credits (10 years of work).

Medicare Part B Covers:

It covers majorly two types of services

1. Preventive Services

2. Medically Necessary Services.

This can be more defined below:

• Physician Services.
• Clinical Research
• Ambulance Services
• Durable Medical Equipments (DME)
• Mental Health (Inpatient, outpatient, Partial Hospitalization)
• Getting a second opinion before surgery and consultation.
• Outpatient Physical Therapies (Occupational therapy & Speech Therapy)

Note: Medicare does not pay for most services like prescription drugs, examinations for prescribing of fitting eyeglasses or hearing aids or routine eye exams. In most cases, Medicare covers screening mammograms one every two years. Pap smears are covered once every three years.

Medicare Part C: Medicare Advantage Plans

A type of Medicare health plan offered by a private company those contracts with Medicare to provide you with all your Part A and part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private fee for Service Plan, special Needs Plans and Medicare Medical Savings Account Plans. If you are enrolled in a Medicare Advantage plan , most Medicare services are covered through the plan and aren't paid for Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medigap: Medicare Supplemental Plan

Medigap is the health insurance that private companies sell to help fill gaps in the Original Medicare Plan. Medigap policies are also known as "Medicare Supplemental Insurance (MSI)". Medigap policies pay most, if not all of the costs for coinsurance under the original Medicare plan. These policies may also cover the original Medicare plan Deductibles. SOme policies may also cover, like prescription drugs. To determine if Medicare is the primary payer, providers must ask the beneficiary about any additional health insurance coverage that he or she may have. To obtain the most updated information, provider should ask about any other health insurance coverage at each patient visit. 

Examples: AARP Supplementary Plan, American Pioneer and Premera Blue Cross.

Medicaid Eligibility:

• Medicaid is a a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, like nursing home care and personal care services. 
• Even if your income exceeds Medicaid income levels in your state, you may be eligible under Medicaid sped down rules. Under the "spend down" process. SOme states allow you to become eligible for Medicaid as "medically needy," even if you have too much income to qualify. This process allows you to "spend down," or subtract, your medical expenses from your income to become eligible for Medicaid.
• Medicaid is always considered as "payer of Last Resort" since Medicaid cannot pay as primary if an individual has other coverage. Also, every Medicaid member must have a valid SSN.

Tricare Eligibility:

• Uniformed Service Members and their families 
• National Guard/ Reserve members and their families \
• Survivors
• Former Spouses
• Medal of honor recipients and their families.

ChampVA Eligibility:

• The spouses or Child of a Veteran who has been rated permanently and totally disabled for a service connected disability by a VA regional office.
• The surviving spouse or child of a Veteran who died from a VA rated service connected disability.
• The surviving spouses or child of a Veteran who was at the time death rated permanently and totally disabled from a service connected disability.
• The surviving spouse or child of a military member who died in the line of duty, not due to misconduct.