rcm glossary


Medicare is a federal health insurance program in the United States that provides coverage for individuals aged 65 and older, as well as certain younger individuals with disabilities.

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What is Medicare?

Medicare is a federal health insurance program in the United States that primarily provides coverage for individuals who are 65 years of age or older, as well as certain younger individuals with disabilities or end-stage renal disease. It was established in 1965 under the Social Security Act and is administered by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS).Medicare is designed to help individuals access affordable healthcare services and reduce the financial burden associated with medical expenses. It is funded through a combination of payroll taxes, premiums paid by beneficiaries, and general government revenue.

Types of Medicare

There are several different types of Medicare coverage, each serving a specific population or addressing particular healthcare needs. The main types of Medicare include:

1. Medicare Part A (Hospital Insurance):

Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Most people do not have to pay a premium for Part A if they or their spouse paid Medicare taxes while working.

2. Medicare Part B (Medical Insurance):

Part B covers medically necessary services and supplies, including doctor visits, outpatient care, preventive services, and durable medical equipment. Beneficiaries typically pay a monthly premium for Part B coverage

.3. Medicare Part C (Medicare Advantage):

Part C refers to Medicare Advantage plans, which are offered by private insurance companies approved by Medicare. These plans combine Part A and Part B coverage and often include additional benefits such as prescription drug coverage (Part D), dental, vision, and hearing services. Medicare Advantage plans may have different costs and rules compared to Original Medicare (Part A and Part B).

4. Medicare Part D (Prescription Drug Coverage):

Part D provides prescription drug coverage to Medicare beneficiaries. It can be obtained as a standalone plan to supplement Original Medicare or as part of a Medicare Advantage plan that includes prescription drug coverage.

Difference between Medicare and Medicaid

Medicare and Medicaid are both government-sponsored healthcare programs, but they serve different populations and have distinct eligibility criteria:

1. Medicare:

As mentioned earlier, Medicare primarily serves individuals who are 65 years or older, as well as younger individuals with disabilities or end-stage renal disease. It is a federal program available to all eligible individuals regardless of income or assets. Medicare is funded through payroll taxes and premiums paid by beneficiaries.

2. Medicaid:

Medicaid, on the other hand, is a joint federal and state program that provides healthcare coverage to low-income individuals and families. Eligibility for Medicaid is based on income and other factors, and it varies from state to state. Medicaid is funded by both the federal government and state governments.

While Medicare is an entitlement program, meaning that eligible individuals are entitled to receive benefits, Medicaid is a means-tested program, meaning that eligibility is determined based on financial need.

Examples of Medicare Coverage

To better understand the scope of Medicare coverage, here are a few examples of services and items that may be covered under different parts of Medicare:

1. Medicare Part A:  

- Inpatient hospital stays  

- Skilled nursing facility care  

- Hospice care  

- Limited home health services

2. Medicare Part B:  

- Doctor visits and consultations  

- Outpatient care, including surgeries and diagnostic tests  

- Preventive services, such as vaccinations and screenings  

- Durable medical equipment (e.g., wheelchairs, walkers)

3. Medicare Part C (Medicare Advantage):  

- All services covered by Part A and Part B  

- Prescription drug coverage (Part D)  

- Additional benefits like dental, vision, and hearing services  

- Health management programs and wellness services

4. Medicare Part D (Prescription Drug Coverage):  

- Prescription medications, including brand-name and generic drugs  

- Coverage may vary depending on the specific plan chosen

It is important to note that Medicare coverage may have limitations, deductibles, copayments, and coinsurance requirements. The specific coverage details and costs can vary depending on the beneficiary's plan, location, and individual circumstances.

In conclusion, Medicare is a federal health insurance program that provides coverage for individuals aged 65 and older, as well as certain younger individuals with disabilities or end-stage renal disease. It consists of different parts, including Part A, Part B, Part C (Medicare Advantage), and Part D (Prescription Drug Coverage), each serving specific healthcare needs. Medicare is distinct from Medicaid, which is a separate program serving low-income individuals and families. Understanding the different types of Medicare coverage and their associated benefits is crucial for healthcare providers, patients, and anyone involved in healthcare revenue cycle management.

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