Medicare vs. Medicaid- What’s the Difference? (Part II)


Welcome to Part II of our two-week series pointing out the differences between the Medicare and Medicaid programs in the United States and the affect each program has on EMS and how that effect differs.

Medicare vs. Medicaid- What’s the Difference? (Part II)

This week we are focusing on Medicaid or in some areas called Medical Assistance.

Title XIX

Medicaid in America was authorized by Title XIX of the Social Security Act and signed into law in 1965 alongside Medicare. While Medicare was intended to provide health coverage for the elderly or disabled, Medicaid was incepted to provide coverage for low income individuals.

All States, the District of Columbia and the United States Territories offer some form of Medicaid. The Federal Government establishes the parameters and each State administers the program.

ACA Expands Medicaid

In 2014, the Affordable Care Act gave authority for the expansion of Medicaid. The expansion now meant that individuals under the age of 65 and families below 133% of the Federal Poverty Level (FPL) were made eligible to participate in the program as well as standardizing CHIP rules for eligibility and providing benefits.

Companion Programs

In addition to Medicaid, the Children’s Health Insurance Program (CHIP) and the Basic Health Program (BHP) are also available to low-income individuals.

CHIP covers children’s health benefits for families whose income is too high for Medicaid up to 200% of the Federal Poverty Level. Additionally the Basic Health Program (BHP) provides health coverage for low income families whose income fluctuates high and low at times.

The Effect

The effect of the Medicaid program can be substantial on EMS systems and the reimbursement that they receive for transports of Medicaid, CHIP and BHP covered patients.

Medicaid payments in many States are absolutely horrible for all services but especially for ambulance transportation. In most States the reimbursement level for ambulance is so grossly underfunded that it’s almost a laugh at times. Plus, many States refuse to pay or follow narrow guidelines for ambulance claims adjudication.

Medicaid eligible patients are a protected class which locks the ambulance service into accepting sub-par reimbursement levels that rarely come close to covering the costs to provide EMS services to these patients.

There are those people we refer to as the “dual eligibles” of age and income level to qualify for Medicare based on their age and Medicaid based on their low income. Many states will not cover the 20% co-pay for Medicare Fee-for-Service and the EMS agency is stuck accepting only the 80% of the Medicare fee schedule for that area with the inability to collect the remaining 20%, given that the patient has no monetary resource to pay the bill.

When the economy is bad…

Over the years, this billing office has seen the lasting effects of a lagging American economy on the bottom line.

People lose their jobs because their place of employment shuts down and in order to protect themselves with health coverage they join the Medicaid ranks. Former President Obama also worked hard to expand the Medicaid program which meant that many times our billing office has reviewed client accounts whose volume of Medicaid patients now accounts for a much larger percentage of the organization’s payer mix, some increasing by nearly double over a few years.

And, this trend then equates to similar or even increased call volume, not followed proportionately by equal revenue increases. Plus, given the nature of our mission and unlike some other healthcare providers, EMS agencies do not have the luxury of refusing to serve Medicaid patients.

Providing the same services at the same cost to patients for less money than we receive from other payers while all the time the Medicaid payer section as a percentage is sometimes doubling, is a difficult balancing act for EMS agency administrators trying desperately to balance their budgets.

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