Coordinating Coverage And Payment Polices For Medicare And Medicaid

By Author: William Richards
Total Articles: 366
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If you’re a dual eligible, that is, you are covered both by Medicare and Medicaid, you may not know or you may be confused about how your coverage and payment policies coordinate. It’s a long-fought battle that has been going on for quite a while.

“It can be difficult coordinating Medicare and Medicaid benefits and payment for services,” notes Alan Weinstock, an insurance broker at MedicareSupplementPlans.com. “Often there are conflicting rules and incentives under existing federal and state laws governing coverage of these patients.”

Coordinating Medicare/Medicaid Benefits

While dual eligibles may be enrolled in either original Medicare or in a Medicare Advantage plan, most are enrolled in original Medicare. Medicare is the primary insurer and covers medically necessary acute care services (i.e. physician, hospital, hospice) and durable medical equipment. Medicaid is the secondary payer and generally covers services not covered by Medicare, wrap-around services, and long-term care.

Problems arise when there are services that could be covered by either Medicare or Medicaid, even if they ...
... are delivered in the same setting. Such services could be covered by Medicare if they are deemed to be rehabilitative, or by Medicaid if they are deemed to be chronic or maintenance care.

The boundaries between Medicare and Medicaid coverage are less clear for enrollees in Medicare Advantage plans than in original Medicare because Medicare Advantage plans can offer additional benefits, such as outpatient prescription drug coverage, preventive services, and vision and dental care – all services that Medicaid often covers.

The Dilemma of Dual-Eligibles

Experts say that dual-eligibles can be even more costly to care for if they live alone, have multiple chronic illnesses and need help with daily activities of living. They run the risk of higher-than-normal rates of depression, mental illness, cognitive impairment and drug and alcohol abuse.

With dual-eligibles care can be fragmented among multiple providers. Where Medicare and Medicaid overlap is a tangled mess of conflicting federal and state rules. However, there is good news on the horizon.

According to experts, in some states, such as Arizona, New York, and Washington, where Medicare and Medicaid are integrated, there have been improved consumer satisfaction, better health outcomes and lower Medicaid costs. The states had to change their Medicaid rules by attaining a waiver from the federal government, but they have approached the dual-eligible problem through managed care.

In addition, there have been studies that have shown that Medicare beneficiaries covered by integrated long-term care programs experience fewer hospital re-admissions, less depression and lower rates of chronic diseases such as hypertension, diabetes, and emphysema. They also are more likely to keep their diseases in check and not suffer complications.

Finally, the new Center for Medicare and Medicaid Innovation was launched in 2010 to explore better ways to deliver healthcare while improving payment systems that can save money. At that time the Innovation Center offered contracts of up to $1 million each for 15 states that designed demonstration projects to fully integrate care for dual eligibles. According to CMS, dual eligibles account for 16 to 18 percent of enrollees in Medicare and Medicaid, but roughly 25 to 45 percent of spending in these programs respectively.

The best Medicare Supplemental Insurance is one that provides full security to the people and hence is called Medigap; Medicare supplemental plans should be beneficial for the people.