HCR 202 Week 4 Government Payers: Medicare and Medicaid Example

Part B, Part C, a Dual Eligible and a Lost Medicaid Card: How Government Payers Work for a Family Practice Where Four in Ten Visits Are Publicly Insured

[Student Name]

University of Phoenix

HCR/202: Medical Insurance

Week 4 Assignment

[Instructor Name]

[Date]

The practice, its payer mix and its patients are composites written for a model paper; program rules and enrollment figures come from the sources listed.

At a composite four-physician family practice, 41% of visits last year were covered by government programs: 26% by Medicare and 15% by Medicaid or its companion program for children. Each program has its own eligibility rules, billing routes and coverage policies, and mistakes in any of them lead to denials or patients billed incorrectly. This paper explains the programs and applies them to four of the practice's patients.

Medicare

Medicare is run by the federal government for three groups: people who have turned 65, younger people who have received disability benefits for a qualifying period and people whose kidneys have failed. Its hospital insurance, Part A, pays for inpatient stays, short skilled nursing stays that follow them, hospice and some home health. Part B, medical insurance, pays for physician services, outpatient care, preventive services and durable medical equipment, with a monthly premium, an annual deductible and 20% coinsurance for most services. Part C, Medicare Advantage, lets beneficiaries receive Part A and B benefits through private plans, and Part D, also sold by private insurers, pays for outpatient prescriptions (Medicare.gov, n.d.).

Medicare Advantage

Medicare Advantage has grown steadily. Freed et al. (2026) reported that 35.2 million of 64.2 million eligible beneficiaries, 55%, were enrolled in Medicare Advantage plans in 2026, and that nearly 8.2 million were in special needs plans for people with particular conditions or with both Medicare and Medicaid. For the practice, Medicare Advantage patients are billed to their plan, not to Medicare, and each plan has its own network, referral and prior authorization rules.

Medicaid

Medicaid provides coverage for people with low incomes and certain other groups. It is financed jointly by the federal government and states and run by each state within federal rules, so eligibility, covered services and payment rates vary. Most states now deliver Medicaid through managed care organizations, private plans paid a monthly amount per member, so the practice must know which plan each Medicaid patient belongs to.

Medicaid and CHIP Enrollment

Enrollment has fallen since pandemic-era continuous coverage ended. The federal Medicaid agency reported 73.2 million people enrolled in Medicaid and CHIP in June 2026, including 66.0 million in Medicaid and 7.2 million in CHIP (Centers for Medicare & Medicaid Services, 2026). Enrollment changes month to month as people renew or lose coverage.

The Children's Health Insurance Program

CHIP fills the gap for children whose household income is above the state's Medicaid limit yet still modest, so private coverage would strain the family budget. In some states it is part of Medicaid; in others it is a separate program with its own plans.

Patient One: Original Medicare

A 72-year-old retired mechanic has Original Medicare Part B and a supplemental policy. The practice bills Medicare's contractor, which pays 80% of the allowed amount after the deductible and forwards the claim automatically to his supplemental plan for the coinsurance.

Patient Two: Medicare Advantage

A 69-year-old retired teacher switched in January to a Medicare Advantage plan. Her old red-white-and-blue Medicare card still works for identification but not for billing. The front desk scanned her plan card and billed the plan, which requires prior authorization for her upcoming MRI. Billing Original Medicare for a Medicare Advantage member is one of the fastest ways to get a denial in January.

Patient Three: Dual Eligible

A 78-year-old widow has Medicare and Medicaid. Medicare pays first; Medicaid pays second and, depending on her eligibility category, covers Medicare's cost sharing. The practice cannot bill her for amounts Medicaid is responsible for, even if Medicaid pays nothing further because its rate is lower. She is enrolled in a special needs plan that coordinates both programs.

Patient Four: A Lost Medicaid Card

A 31-year-old mother arrived for a visit with her Medicaid card, but the eligibility check showed her coverage had ended the previous month at renewal because a form was mailed to an old address. The practice's financial counselor helped her submit the renewal online the same day, and many states reinstate coverage retroactively when the person remains eligible. Federal law enacted in 2025 adds more frequent eligibility checks and work requirements for many adults covered through Medicaid expansion, starting in late 2026, so the practice expects more coverage gaps.

How the Programs Pay the Practice

Payment rates differ by program as well. Original Medicare pays from the national physician fee schedule. Medicare Advantage plans usually pay the practice a rate tied to that schedule under their contracts, though some use capitation or bonuses for quality. Medicaid fee-for-service rates are set by the state and in many states are lower than Medicare's for office visits, while Medicaid managed care plans negotiate their own rates. For the practice, a patient who moves from Original Medicare to a Medicare Advantage plan, or from Medicaid fee-for-service to a managed care plan, may bring a different payment, different rules and a different claims address, even though the patient's care does not change.

Other Government Payers

TRICARE covers military families, the Veterans Health Administration provides care to eligible veterans and can pay community providers through its community care program, and workers' compensation covers work injuries. Each has its own claims rules.

What Staff Check by Program

Original Medicare: verify Part B entitlement and any supplemental plan. Medicare Advantage: identify the plan, confirm network status and check authorization rules. Medicaid: check eligibility at every visit and identify the managed care plan. Dual eligibles: bill Medicare first and never bill the patient for Medicare cost sharing covered by Medicaid.

Conclusion

Medicare and Medicaid cover four in ten visits at the practice, but they work very differently. Medicare is federal and age- or disability-based, increasingly delivered through private Medicare Advantage plans. Medicaid is run by states for people with low incomes, mostly through managed care, and its enrollment changes often. Knowing the rules for each, and for patients with both, keeps claims paid and patients protected from improper bills.

References

Centers for Medicare & Medicaid Services. (2026). June 2026 Medicaid & CHIP enrollment data highlights. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights

Freed, M., Fuglesten Biniek, J., Damico, A., Ochieng, N., & Neuman, T. (2026). Medicare Advantage in 2026: Enrollment update and key trends. KFF. https://www.kff.org/medicare/medicare-advantage-in-2026-enrollment-update-and-key-trends/

Medicare.gov. (n.d.). Parts of Medicare. Centers for Medicare & Medicaid Services. https://www.medicare.gov/basics/get-started-with-medicare/medicare-basics/parts-of-medicare