Medicare & Medicaid A Guide to Government Payer Medical Billing

Navigating Medicare and Medicaid: A Guide to Government Payer Medical Billing

What is the difference between Medicare & Medicaid?

Medicare is a federal program that provides health coverage for individuals who are 65 years or older or those under 65 with a disability, regardless of their income.

Medicaid If you have a very low income, Medicaid is a program that can provide you with essential health coverage and support. It is an important government initiative that can help you access the healthcare services you need to stay healthy.

Table of Contents

History of Medicare & Medicaid

Medicare was first established in 1965. It is a federal health insurance program primarily designed for individuals aged 65 and older. It also covers younger individuals with disabilities and those suffering from specific medical conditions. These conditions specifically include end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS). The program is administered by the Centers for Medicare & Medicaid Services (CMS). This program consists of four major parts that have been discussed below comprehensively. Each program addresses specific healthcare needs and targets patients.

Medicaid is a Program for Low-Income Individuals. It is a joint federal and state program that provides health coverage for individuals with low income and limited resources. Although the federal government has already set guidelines and regulations, each state administers its own Medicaid program as per the needs of its population. Medicaid is considered a primary program that serves various demographics. It specifically serves low-income adults, children, pregnant women, elderly individuals, and all other people with disabilities. By and large, it can be said that it serves almost every single individual in the country.

Four Parts of Medicare 

1.     Medicare Part A ─Hospital Insurance

Medicare Part A provides coverage for inpatient hospital stays. It also covers skilled nursing facility care, hospice care, and some home healthcare services. It is funded through payroll taxes, and it covers eligible individuals automatically when they turn 65 years old.

2.     Medicare Part B ─Medical Insurance

Medicare Part B covers outpatient care and preventive services. Additionally, it also covers visits of healthcare professionals and other medically necessary services. Recipients of medical services typically pay a monthly premium for Part B coverage. Apart from that, some may be subject to income-based surcharges.

3.     Medicare Part C ─Medicare Advantage

Medicare Part C is also known as Medicare Advantage. It offers an alternative to traditional Medicare coverage. These plans are provided by private insurance companies that must be approved by Medicare. These types of plans often include additional benefits like vision and dental coverage.

4. Medicare Part D: Prescription Drug Coverage

Medicare Part D is a prescription drug coverage plan. It is offered to patients by private insurance companies. Beneficiaries of this plan can enroll in a standalone Part D plan. In the meanwhile, they can also choose a Medicare Advantage plan that includes prescription drug coverage.

Medicaid Eligibility and Coverage

Medicaid eligibility is determined by factors like income and household size, apart from that it also focus onspecific demographic characteristics for determining the eligibility of an individual. The Affordable Care Act (ACA) expanded Medicaid eligibility in participating states. It is quite helpful because it allows more low-income individuals and families to access this coverage.Many states are administering Medicaid through managed care organizations (MCOs). These are private health insurers that contract with state Medicaid programs as well. Medicaid-managed care has the primary objective to improve coordination of care and controlling the costs of treatment. All this helps the country to enhance health outcomes for the deserving general public.

Medical Billing in Medicare and Medicaid

The beneficiaries of Medicare and Medicaid require a thorough understanding of guidelines, regulations, and reimbursement processes described by CMS. That is the reason that Healthcare providers must navigate a complex landscape. It will help them to ensure accurate billing, compliance with regulations, and timely reimbursement. The following sections outline key aspects of medical billing in Medicare and Medicaid that will enrich your understanding of the reimbursement process.

a. Enrollment of Healthcare Provider

In order To bill Medicare for services, healthcare providers must enroll in the Medicare program. This process involves submitting an application to CMS. Moreover, healthcare providers must meet specific requirements prescribed by CMS in order to have license numbers. Once enrolled successfully, the providers receive a unique National Provider Identifier (NPI) that is used in all Medicare transactions.

b. Medicare Fee-for-Service (FFS) Billing

Medicare FFS is the traditional payment model where providers bill Medicare directly for each service rendered. That is the reason, comprehensive understanding of Medicare Physician Fee Schedule (MPFS) is considered crucial for accurate billing. Apart from that, the providers must use appropriate Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes when submitting claims for reimbursements.

c. Medicare Advantage Billing

It is a fact that billing processes may vary among different Medicare Advantage plans. That is the reason, the providers must be familiar with the specific requirements of each plan. Providers participating in Medicare Advantage plans can bill the private insurance companies that offer these plans for reimbursements.

d. Prescription Drug Billing

As per CMS requirements, Pharmacies must also be enrolled in Medicare Part D to receive reimbursement for prescription drugs.

Key Amendments in Medicaid State Plan Year 2024

A Medicaid and CHIP state plan serves as a critical agreement between a state and the federal government. This plan outlines the administration of Medicaid and CHIP programs within that the particular state. This agreement ensures that all players must follow federal rules and it must be eligible to claim federal matching funds for program activities. The state plan provide complete details regarding the groups of individuals and reimbursement methodologies. It also focuses on ongoing administrative activities.

By and large, It can be said that when a state intends to modify program policies, it must submit State Plan Amendments (SPAs) to the Centers for Medicare & Medicaid Services (CMS) for formal approval. SPAs can also be used to request permissible program changes and corrections. Furthermore, it can also be used to provide updates to the Medicaid and CHIP state plan.

Medicaid State Plan Amendments

Scope of Amendments

The primary purpose of a Medicaid State Plan is to establish a framework for the administration of Medicaid and CHIP programs within a state. This plan outlines the commitment of the state to comply with federal regulations. Therein the case, SPAs play a crucial role in the dynamic landscape of Medicaid and CHIP programs. These amendments are submitted to CMS when a state plans to make changes to its programs/policies.

Medicaid State Plan Key Amendments

1. Transmittal Number: AZ-23-0025 (-Arizona)

This amendment Updates fee schedule rates for all non-institutional services in Arizona. However, It excludes outpatient hospital services.

Approval Date: 01/23/2024

2. Transmittal Number: VA-23-0020 (-Virginia)

This amendment adds assurance that the Department of Medical Assistance Services will modify ‘coverage billing codes’ in response to changes in advisory recommendations. It also makes a technical change to revise a reference in the Patient Protection and Affordable Care Act.

Approval Date: 01/22/2024

3. Transmittal Number: DC-23-0015 (-District of Columbia)

The purpose of this amendment is to update, clarify, and streamline language in the state plan. Includes streamlining language for certain therapy modalities. Apart from that, this amendment is also helpful in updating supervision requirements for behavioral health providers. It clarifies education and experience requirements as well.

Approval Date: 01/22/2024

4. Reimbursement Updates (AZ-23-0025, AZ-23-0024)

All these Amendments address updates to fee schedule rates for various services, which helps ensure that reimbursement aligns with current standards.

5. Coverage Modifications (VA-23-0020, NV-23-0031, CA-23-0037)

These Amendments include changes to coverage. For instance, it may include adding providers like pharmacists for specific treatments and expanding the list of billable practitioners.

6. Qualification and Licensing Requirements (PA-24-0003)

These amendments may focus on revising qualifications and licensing requirements for specific services. For instance, these amendments may focus on improving peer support services and certified peer specialists.

Medicare Monoclonal Antibody COVID-19 Infusion Program

The Medicare Monoclonal Antibody COVID-19 Infusion Program is considered the most positive outcome from Medicare and Medicaid. This infusion program provides instructions for the use of certain investigational monoclonal antibody therapies that are authorized by the FDA. These therapies include: BAMLANIVIMAB, CASIRIVIMAB, IMDEVIMAB, and ETESEVIMAB. All these therapies are authorized for the treatment of mild-to-moderate COVID-19 in high-risk adults.

Moreover, these are also authorized in pediatric patients with positive test results. That is the reason, it is essential to note that these therapies should be administered in a closed setting. Healthcare providers can should immediately address severe infusion reactions like anaphylaxis. He is also responsible for activating emergency if he finds ongoing treatment ineffective.

Medicaid Data Collection Tool (MDCT) Portal

In the ever-evolving healthcare industry, information plays a pivotal function in shaping policy decisions and ensuring the powerful functioning of applications, which includes Medicaid and the Children’s Health Insurance Program (CHIP). The Centers for Medicare and Medicaid Services (CMS) led this effort with the help of the Medicaid Data Collection Tool (MDCT) and associated systems. This article discusses the complexities of the MDCT Portal and its subsystems. It will also shedding light on how they make a contribution to the comprehensive information, monitoring, and control of healthcare projects across states.

The CMS collects vital facts from the USA and its territories to gain insights into the Medicaid and CHIP packages. At the coronary heart of this records collection attempt is the Medicaid Data Collection Tool (MDCT) and its suite of programs, designed by using the Center for Medicaid and CHIP Services (CMCS). These packages are meticulously created to acquire statistics important for monitoring, dealing with information, and reviewing Medicaid and CHIP applications on a country-to-country basis.

In order to facilitate seamless reporting of diverse data types to CMS, several systems and documents are at the disposal of states. These include the CHIP Annual Reporting Template System (CARTS), Statistical Enrollment Data System (SEDS), Quality Measures Reporting (QMR), Managed Care Reporting (MCR), and the overarching MDCT Systems.

CHIP Annual Reporting Template System (CARTS)

CARTS serves as a platform for states to report annual data to CMS regarding the coverage of their CHIP state plan. For assistance, states can reach out to the help desk at

Statistical Enrollment Data System (SEDS)

SEDS focuses on collecting CHIP and Medicaid quarterly enrollment data from states on a quarterly basis. For assistance, states can contact the help desk at

Quality Measures Reporting (QMR)

QMR plays a crucial role in measuring and quantifying healthcare processes to ensure quality healthcare for Medicaid beneficiaries. States looking for assistance with QMR can email the help desk at

QMR Core Set Measures Additional Information

For additional information regarding the performance measurement for Adult and Child Core Sets, you can visit the Performance Measurement.

Managed Care Reporting (MCR)

MCR is instrumental in collecting state data related to Managed Care Plans and their performance. MCR Reports cover various aspects. States can access instructions regarding MCR access through CMS Identity Management (IDM).

The Inflation Reduction Act and Medicare

The Inflation Reduction Act delivers significant financial relief to millions of Medicare beneficiaries. This act enhances accessibility of people to affordable treatments. Moreover, it also fortifies the Medicare Program in the short and long term. The recent legislation brings about positive changes to Medicare and Medicaid. The primary aim of these legislations is to expand benefits and reduce drug costs. Moreover, these will also be helpful in maintaining stability in prescription drug premiums.

IRA Drug Part D Improvements

Medicare recipients will experience a reduction in prescription drug expenses and it will also offer a refurbished prescription drug program. This will particularly include:

  • Insulin at a monthly cost of $35 per covered prescription.
  • Access to recommended adult vaccines without cost-sharing.
  • Implementation of a yearly cap on out-of-pocket prescription drug costs in Medicare set at $2,000 in 2025.

IRA Negotiation Medicare Drug Price Negotiation

The legislation empowers Medicare to engage in direct negotiations with drug manufacturers. This will ultimately help them to lower the prices of the most expensive single-source brand-name drugs. This initiative will certainly increase access to innovative and life-saving treatments. This will probably result in lower costs for both Medicare and its beneficiaries.

IRA Payment Inflation Rebates in Medicare

Under the new law, the drug companies must pay Medicare a rebate under particular circumstances. This measure will strengthen Medicare for both current and future enrollees. In the meantime, it will discourage unreasonable price hikes by pharmaceutical companies.

IRA Insulin Changes to Medicare Part B

Modifications to the Medicare Part B program will enhance access to high-quality and affordable biosimilars. Moreover, a cost-sharing cap of $35 per month will be imposed on insulin used under this legislation.

Key Challenges for Medicare and Medicaid

Law Policy and Regulation Medicaid Insurance

The Medicaid program has a long history, and it has been positioned as the health safety net for low-income populations. As per recent data available, it has come to the knowledge that Medicaid provides coverage for approximately 77.9 million people. It provides all types of healthcare treatments to its beneficiaries. For instance, it provides coverage for physician visits and inpatient and outpatient hospital services. It also focuses on providing nursing facilities and home health services. Therein the case, the big number is a problem because it requires continuous changes and updates in the policy/regulations at the state level.

It has been observed that during the pandemic, approximately 15 million people lost their jobs. They were all enrolled in Medicaid under the Families First Coronavirus Response Act. This act was signed into law in 2020 in response to the economic downturn. As per fresh statistics, 93 million were enrolled in Medicaid because of “churn.”This is a persistent feature of enrollment that happens when employment status suddenly changes. This act makes a person temporarily eligible for enrollment in this program. By and large, it can be said that all these state policies and regulations are increasing the burden on Medicaid insurance.

Sustainability of Medicaid

As per financial statistics, Medicaid accounts for 16.7% of national health spending, which is $688 billion. It has funding shared between states (32.4%) and the federal government (67.6%). As per statistics, states spend an average of 28.7% of their budgets on Medicaid. However, it ranges widely based on determinations for special populations like dual eligibility and people with an addiction. Apart from that, it also depends on the economic circumstances in the particular state.

Medicaid provides easy access to primary care services similar to private insurance. Some critics argue against program expansion because they suggest that eligibility criteria should be stricter. They opine that not all people should be allowed to enroll in the programs at their own will. They should make copayments, and they must try to find employment at their best before enrolling.

Eligibility and State Oversight

The Centers for Medicare & Medicaid Services (CMS) specifies that individuals can qualify for free and low-cost care through Medicaid. This program offers health coverage for low-income individuals, families, and children in all states. It also provides coverage for pregnant women, the elderly, and those with disabilities.

 Medicaid extends coverage to all low-income adults below a specific income threshold. However, eligibility requirements vary from state to state. In 37 states, private managed care organizations are responsible for care coordination; however, they are hesitant to share data. This limits the availability of timely clinical, financial, and administrative data for the people overseeing the program. That is the reason that real-time data is considered essential for effective management and care.

Loss of Temporary Coverage Due to the Pandemic

It has been observed that during the pandemic, enrollment in Medicaid increased by 8.9% in tenurefrom July 2020 to May 2021 and by 6.1% in tenure from July 2019 to July 2020.As per statistics, approximately 15 million people became unemployed due to the pandemic. Consequently, Congress authorized temporary coverage of individuals through state Medicaid programs until April 15, 2022. The long-term impact of the pandemic on employment is unknown. However, some statistics have been found concerning. As per reports, 4 million people will not return to the workforce, which means the burden on Medicaid will continue to exist.

It is a fact that Loss of temporary coverage is an impending danger to enrollees. Currently, their financial insecurity is heightened due to inflation. Food and energy prices have already increased, which hit low-income households badly. All this is rendering copays and out-of-pocket requirements in some state Medicaid programs that are considered quite problematic.

Lack of Public Support

Polls show many people believe Medicaid is an unaffordable/unnecessary government entitlement program that benefits the ineligible and those who choose not to purchase coverage for themselves and their families.A significant aspect is that 60% of adult Medicaid enrollees work full-time. Until now, access to affordable employer-sponsored coverage has been negligible.

Additionally, Medicaid coverage is linked to lower health costs because regular primary care reduces unnecessary hospital and emergency department visits. That is the reason it is being assumed that coordinated care with the help of high-value in-network primary care practices can cut enrollee health costs by up to 25%. By and large, it can be said that the Sustainability of the Medicaid program relies on voter support. It is crucial for its long-term viability as well.


By and large, it can be concluded that this article provides a detailed understanding of Medicare and Medicaid. It focuses on essential government programs that can ensure healthcare access for diverse groups in the United States. Medicare serves individuals aged 65 and older, as well as those with disabilities. It offers four distinct parts that cover various healthcare needs. Contrariwise, Medicaid is a joint federal and state initiative. It is extended to health coverage for low-income individuals across demographics.

The billing processes for these two programs demand careful consideration from healthcare providers. It is requiring enrollment in Medicare for billing and adherence to State Plan Amendments in Medicaid. Apart from that, major Challenges include eligibility oversight, temporary coverage, and the need for sustained public support. All these challenges have been part of Medicare and Medicaid. All these challenges must be given special heed to avoid failure in providing quality healthcare.

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