Mastering Insurance Fundamentals for Medical Billing

Lesson 1: The Four Primary Payer Types

A "payer" is the entity that pays the claim. Your role requires knowing who each payer is and the rules for getting them to pay.

1. Government-Sponsored Programs

These are public, tax-funded programs with strict eligibility rules based on law.

Medicare

Federal health insurance for individuals aged 65 and older, certain younger people with disabilities, and those with End-Stage Renal Disease (ESRD) or ALS

Medicaid (and CHIP)

A joint federal and state program for individuals and families with limited income and resources. In states that expanded Medicaid under the ACA, adults qualify if their household income is at or below 138% of the Federal Poverty Level (FPL). Eligibility for children, pregnant women, and the disabled varies by state

TRICARE

The healthcare program for active-duty service members, retirees, National Guard/Reserve members, and their eligible family members. Eligibility is tied to military service and registration in the Defense Enrollment Eligibility Reporting System (DEERS).