MLN Booklet

MEDICARE AND MEDICAID BASICS

Medicare Medicaid
Federal health care coverage for: Cooperative Federal and State health care
coverage for:
People Certain
aged 65 people Pregnant
or older under 65 with women
Low-income
disabilities adults
People of any age with
End-Stage Renal Disease Children

More
than 58.5 beneficiaries More 72 beneficiaries enrolled
million enrolled in Medicare than million in Medicaid, including
more than
28
More million
children
than 6,100 hospitals

skilled
15,000 nursing facilities

1.2 physicians
million and other
health care
practitioners
and service
providers

Target Audience: Medicare and Medicaid Providers

The Hyperlink Table, at the end of this document, provides the complete URL for each hyperlink.

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Table of Contents
Quick Facts........................................................................................................................................... 3
Beneficiaries......................................................................................................................................... 4
Dual Eligible Beneficiaries................................................................................................................ 5
Covered Services................................................................................................................................. 5
Other Common Types of Coverage.................................................................................................... 6
Resources............................................................................................................................................. 7
General Information.......................................................................................................................... 7
Provider Enrollment.......................................................................................................................... 7
Billing and Claims Submission.......................................................................................................... 7
Payment............................................................................................................................................ 8
Appeals............................................................................................................................................. 8
Program Integrity.............................................................................................................................. 8
Program Guidance............................................................................................................................ 8

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The Centers for Medicare & Medicaid Services (CMS) administers Medicare and Medicaid along with
other Federal health care programs and services. This booklet provides an overview of the Medicare
and Medicaid Programs and some brief information on other types of health coverage.

Quick Facts

Medicare Medicaid
Medicare is a national program Medicaid is a network of Statewide
administered by the Federal government, programs administered by State
comprising: governments following broad national
guidelines established by Federal statutes,
●● Part A – Hospital Insurance
regulations, and policies.
Inpatient hospital, inpatient skilled
nursing facility, hospice, and some home Health care coverage for:
health services
●● Low-income adults
●● Part B – Medical Insurance
●● Pregnant women
Physician services, outpatient care,
durable medical equipment, home ●● Children
health services, and many
preventive services Eligibility varies from State to State.
●● Part C – Medicare Advantage (MA) Medicaid is the nation’s largest payer of
Medicare-approved private insurance mental health services, long-term care
companies that provide all Part A services, and births. Medicaid pays for
and Part B services and may provide 40 percent of all births.
prescription drug coverage and other
supplemental benefits
●● Part D – Prescription Drug Benefit
Medicare-approved private insurance
companies that provide outpatient
prescription drug coverage
Health care coverage for:
●● People 65 or older
●● People with certain disabilities
●● People diagnosed with end-stage renal
disease (ESRD)
Medicare is the nation’s largest payer of
inpatient hospital services for the elderly
and people with ESRD.

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Beneficiaries

Medicare Medicaid
Health insurance for: Individuals must meet eligibility requirements
and State rules.
●● People 65 and older
Federal law requires States to cover
●● People younger than age 65 with certain
certain eligibility groups and gives them the
disabilities entitled to Social Security flexibility to cover others.
disability or Railroad Retirement Board
benefits for 24 months (the 24-month All States cover eligibility groups that serve
waiting period is waived for people with the following populations:
amyotrophic lateral sclerosis [ALS], also
known as Lou Gehrig’s disease) ●● Children and adolescents
●● People of any age with ESRD ●● Parents or caretaker relative of
minor children
●● Certain people with disabilities or blindness
●● Pregnant women
●● Seniors
●● Youth “aging out” of foster care

For many eligibility groups, individuals must

meet certain resource limits.
In addition, individuals must meet State and
Federal requirements for:
●● Immigration status
●● Residency
●● U.S. citizenship

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Dual Eligible Beneficiaries

“Dual eligible beneficiaries” generally describes beneficiaries eligible for both Medicare and
Medicaid. The term includes beneficiaries enrolled in Medicare Part A, Part B, or both and
receiving full Medicaid benefits or assistance with Medicare premiums or cost sharing through
one of these Medicare Savings Program (MSP) eligibility groups:
●● Qualified Medicare Beneficiary (QMB) Program: Helps pay premiums, deductibles,
coinsurance, and copayments for Part A, Part B, or both programs
●● Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums
●● Qualifying Individual (QI) Program: Helps pay Part B premiums
●● Qualified Disabled Working Individual (QDWI) Program: Pays the Part A premium for
certain disabled and working beneficiaries who have disabilities
For more information, refer to the Dual Eligible Beneficiaries Under Medicare and Medicaid booklet.

Covered Services

Medicare Medicaid
Beneficiaries may choose coverage Some Medicaid Programs pay for care
as follows: directly. Others use private insurance
companies to provide Medicaid coverage.
●● Part A and Part B services through the
Original Medicare Program with optional States must cover certain services through
Part D coverage through a stand-alone their Medicaid Program, including:
Prescription Drug Plan
●● Doctor visits
●● Part A and Part B services through an
●● Inpatient and outpatient hospital services
MA Plan if they reside in its service area,
with Part D coverage included in some ●● Mental health services
MA Plans ●● Needed medications
Note: Some beneficiaries get a Medicare ●● Prenatal care and maternity care
supplement plan (also called
●● Preventive care, such as immunizations,
Medigap) for expanded coverage in
the Original Medicare Program mammograms, and colonoscopies

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Covered Services (cont.)

Medicare Medicaid
Part A helps cover: States may choose to cover added
services. Some of these include:
●● Inpatient hospital care
●● Skilled nursing facility care ●● Dental services
●● Hospice care ●● Home and community-based services
●● Home health care ●● Physical therapy
●● Prosthetic devices
Part B helps cover:
●● Vision and eyeglasses
●● Services from doctors and other health Children and adolescents get vision,
care providers dental, hearing, and other services
●● Outpatient care through the Medicaid Early and
●● Home health care Periodic Screening, Diagnostic, and
Treatment (EPSDT) benefit
●● Durable medical equipment
●● Many preventive services

Part C includes all benefits and services

covered under Part A and Part B and may
include extra benefits and services for an
extra cost.
Part D helps cover the cost of
prescription drugs.

Other Common Types of Coverage

You may encounter patients with health care coverage other than Medicare or Medicaid. These
programs include:
●● Private insurance coverage (such as group health plan or retiree coverage)
●● TRICARE
●● COBRA
●● Workers’ Compensation
●● Liability insurance coverage

For more information on these types of coverage, take the Medicare Secondary Payer Provisions
web-based training course. Need help accessing the course? Find information in The Medicare
Learning Network® (MLN) Learning Management System (LMS) FAQs booklet.

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Resources
General Information
Medicare Medicaid
Find additional resources about the Medicare Find additional resources about the Medicaid
Program on the Medicare.gov website. Program on the Medicaid.gov website.
The Social Security Administration processes Contact your State Medicaid office with questions.
Medicare enrollment applications. See if your patient qualifies for Medicaid in your
The searchable Medicare Coverage Database State based on income alone using the Medicaid
allows you to learn about any national and local & CHIP Coverage tool.
determinations regarding coverage for specific Share easy-to-read infographics on common
medical services. Medicaid questions or find key messages
See if your patient qualifies for Extra Help With and tips from the Medicaid Program Integrity
Medicare Prescription Drug Plan Costs. Education webpage.

Provider Enrollment
Medicare Medicaid
Find health care professional-specific information Find more information about your State’s Medicaid
about enrolling in Medicare through MLN provider- Program on the State Overviews webpage.
supplier enrollment educational products.

Billing and Claims Submission

Medicare Medicaid
Find information about submitting Medicare While each State Medicaid Program varies,
claims in the Medicare Billing: 837I and Form general rules require that you:
CMS-1450 and the Medicare Billing: 837P and ●● Bill only for covered services
Form CMS-1500 publications.
●● Ensure beneficiaries are eligible for services
where they are furnished
●● Ensure medical records are accurate, legible,
signed, and dated
●● Return any overpayments within 60 days

Find more information about your State’s

Medicaid Program on the State Overviews
webpage.

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Payment
Medicare Medicaid
Find information about payment for your provider Find more information about your State’s
type on the MLN Publications webpage. Enter Medicaid Program on the State Overviews
“Medicare Payment Policy” in the Filter field. webpage.

Appeals
Medicare Medicaid
Find information about Medicare appeals in Find more information about your State’s
the Medicare Parts A & B Appeals Process Medicaid Program on the State Overviews
booklet and the two web-based trainings webpage.
“Part C Organization Determinations,
Appeals, & Grievances” and “Part D Coverage
Determinations, Appeals, & Grievances” on the
MLN LMS.

Program Integrity
Medicare Medicaid
Find information about compliance and fraud, Find information about program integrity in the
waste, and abuse on the MLN Provider Medicaid Program on the Medicaid Program
Compliance webpage. Integrity Education webpage. Find more
information about your State’s Medicaid Program
on the State Overviews webpage.

Program Guidance
Medicare Medicaid
Visit the CMS Regulations & Guidance webpage CMS issues guidance to State Medicaid
for information on rulings, transmittals, manuals,directors, State health officials, and other
and other guidance. stakeholders regarding Medicaid operational
MLN Matters® Articles are national articles that issues. This guidance comes through letters,
inform health care professionals about the latest informational bulletins, and frequently asked
changes to CMS programs. questions. CMS also issues Federal regulations
that codify statutory provisions and policies that
Sign up for MLN electronic mailing lists and have been previously outlined in subregulatory
access MLN Connects® newsletters on the MLN guidance. Search these documents on the
News & Updates website. Medicaid Federal Policy Guidance webpage.

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Hyperlink Table

Embedded Hyperlink Complete URL

CMS Regulations & Guidance https://www.cms.gov/Regulations-and-Guidance/
Regulations-and-Guidance.html
Contact Your State Medicaid Office https://www.medicaid.gov/about-us/contact-us/
With Questions contact-state-page.html
Dual Eligible Beneficiaries Under Medicare https://www.cms.gov/Outreach-and-Education/
and Medicaid Medicare-Learning-Network-MLN/MLNProducts/
MLN-Publications-Items/CMS1244469.html
Easy-To-Read Infographics on Common https://www.cms.gov/Medicare-Medicaid-
Medicaid Questions Coordination/Fraud-Prevention/Medicaid-
Integrity-Education/infographics.html
Extra Help With Medicare Prescription Drug https://secure.ssa.gov/i1020/start
Plan Costs
Key Messages and Tips https://www.cms.gov/Medicare-Medicaid-
Coordination/Fraud-Prevention/Medicaid-
Integrity-Education/key-messages-and-tips.html
Medicaid & CHIP Coverage Tool https://www.healthcare.gov/medicaid-chip
Medicaid Early and Periodic Screening, https://www.cms.gov/Medicare-Medicaid-
Diagnostic, and Treatment (EPSDT) Coordination/Fraud-Prevention/Medicaid-
Integrity-Education/Downloads/infograph-
Medicaid-EPSDT-[August-2015].pdf
Medicaid Federal Policy Guidance https://www.medicaid.gov/federal-policy-
Guidance
Medicaid Program Integrity Education https://www.cms.gov/Medicare-Medicaid-
Coordination/Fraud-Prevention/Medicaid-
Integrity-Education/edmic-landing.html
Medicare Billing: 837I and Form CMS-1450 https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/
MLN-Publications-Items/ICN006926.html
Medicare Billing: 837P and Form CMS-1500 https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/
MLN-Publications-Items/ICN006976.html
Medicare Coverage Database https://www.cms.gov/medicare-coverage-
database

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Hyperlink Table (cont.)

Embedded Hyperlink Complete URL

Medicare Parts A & B Appeals Process https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/
MLN-Publications-Items/CMS1243294.html
Medicare Secondary Payer Provisions https://learner.mlnlms.com
MLN LMS https://learner.mlnlms.com
MLN Matters® Articles https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNMatters
Articles
MLN News & Updates https://www.cms.gov/Outreach-and-Education/
Outreach/FFSProvPartProg/Index.html
MLN Provider Compliance https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/
ProviderCompliance.html
MLN Provider-Supplier Enrollment Educational https://www.cms.gov/Medicare/Provider-
Products Enrollment-and-Certification/MedicareProvider
SupEnroll/Downloads/Medicare_Provider-
Supplier_Enrollment_National_Education_
Products.pdf
MLN Publications https://www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/MLNProducts/
MLN-Publications.html
Social Security Administration https://www.ssa.gov/benefits/medicare
State Overviews https://www.medicaid.gov/state-overviews
The Medicare Learning Network® (MLN) https://www.cms.gov/Outreach-and-Education/
Learning Management System (LMS) FAQs Medicare-Learning-Network-MLN/MLNProducts/
MLN-Publications-Items/ICN909182.html

Medicare Learning Network® Product Disclaimer

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department
of Health & Human Services (HHS).

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