Healthcare Eligibility

Written by Kimberly Clark
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Healthcare eligibility is the process by which it is determined if a person qualifies to receive benefits under a particular healthcare plan. In most cases, this determination is used to verify whether or not a patient is eligible to receive free or low cost medical or hospital services under the Medicaid or Medicare programs. A participant's eligibility in these federal regulated programs is decided on the state level.

Medicaid is provided to low-income people to help them pay for medical attention. The enrollment qualifications vary from state. In most cases though, a person who qualifies for Medicaid also qualifies for Medicare.

One problematic aspect of billing is determining eligibility for Medicare. A patient's insurance information can be attained through the Internet. This makes billing quicker and easier. Hospitals get correctly reimbursed with a minimum of delay, and patients can avoid dealing with payment denials down the line.

Medicare Eligibility

The Medicare program is broken into two parts. Part A is often referred to as hospital insurance and can be used to cover a patient's stay hospital, hospice, and limited time in a nursing home facility. Part B is called medical insurance and is used to pay for other professional services such as doctors and other specialists' fees, which might be incurred during a hospital stay.

A person qualifies for free Medicare, under Part A, if they are 65 years old or older and receiving either retirement or disability benefits from Social Security or the Railroad Retirement Board. People who are 65 years old or older and have end-stage renal disease (permanent kidney failure) qualify as well. Lastly, someone who had a Medicare covered government job is also eligible. In this case their spouse qualifies too.

People who qualify under Part A are automatically qualified for Part B. A person, who does not meet the free Medicare criteria, can receive the same benefits by paying a small monthly fee. The person must first enroll in Part B, be 65 years or older and have continuously lived in the United States for five years just prior to applying.


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