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Medicaid is a social welfare program provided by the federal government. Individuals eligible for Medicaid have a low income. It includes “all US citizens aged 18–65 years who live under 138% of the federal poverty level (FPL)” (Courtney-Brooks, Pelkofski, Engelhard, & Duska 2013). Medicare is a federal program for the elderly who are 60 five years old or older or individuals who are younger than 65 years old with a disability. It is a social insurance for Americans. After the Affordable Care Act was passed, about “16–18 million more Americans” were provided access to care through the Medicare expansion (Courtney-Brooks, Pelkofski, Engelhard, & Duska 2013).
In the Commonwealth of Virginia, the eligibility for Medicare is stringent. Courtney-Brooks, Pelkofski, Engelhard, and Duska (2013) note individuals between “18–65 years are not eligible for Medicaid regardless of income unless they are disabled, pregnant, or have dependent children”. However, pay scales range from 0% to 100% co-pay “based on income, assets, and number of dependents to determine the amount of money a patient must pay” (Courtney-Brooks, Pelkofski, Engelhard, & Duska 2013). Funds and grants for Medicare individuals, including the Virginia Health Reform and Innovation Fund, is used to ” reduce growth in health care spending or to improve the quality of delivery of health care services” (Pickral, 2013). In 2019, Virginia expanded Medicaid and was expecting to have “400,000” individuals eligible, without the expansion “138,000” individuals would not otherwise have access to coverage (Norris, 2020). Virginians that live “138 percent of the poverty level (in 2019, that’s about $17,236 for a single person, and about $29,435 for an adult in a household of three people)” were eligible for Medicaid (Norris, 2020). Norris (2020) note starting this year in 2020, Virginia is “responsible for 10 percent of the cost” of the Medicaid expansion versus in the previous year’s 7%. The federal government would pay the remaining 80%. Over the next decade, Virginia will receive “$22.8 billion” dollars in additional federal funding (Norris, 2020).
The Affordable Care Act has dramatically impacted both Medicare and Medicaid. The expansion of the Affordable Care Act was intended to help low-income uninsured patients to be able to provide affordable care for themselves and their families. The act improved federal health care coverage by providing more flexible plans that patients could choose from.
Reimbursement from Medicare and Medicaid can vary depending on the procedure code and the state it is claimed in. However, when providers inflate their billing price to abuse, the reimbursement rate contributes to the increasing health care expenditure in the United States. However, not all reimbursements to providers may not be what they expect, resulting in a loss of revenue. Medicare and Medicaid can also refuse to pay for procedures. It can result in a financial burden to the patient, who is left with the bill from the provider.
Unfortunately, some providers and patients will abuse the federal funded programs to receive the maximum amount of payment. Medical providers will bill Medicare Medicaid for unnecessary procedures that were never performed to receive payment. Some medical providers or offices will inflate the cost of their procedure using a billing code to receive more reimbursement from these programs. The Anti-Kickback Statute and Stark Law prohibit providers from receiving payment for anything of value in exchange for referrals of patients who will receive treatment paid by Medicare and/or Medicaid. Patients can be involved with fraud claims by providing their insurance number to the provider to bill, and the patient will admit to receiving the medical treatment that was never performed in exchange for something else.