NUR 5290 Module 2 Access and Coverage Analysis Example

Covered but Still Exposed: Eligibility Rules, Cost Sharing and Who Pays the Facility Fee at a Hospital-Owned Clinic

Student Name

Master of Science in Nursing (MSN), Thomas Edison State University

NUR-5290: U.S. Health Policy and Global Health

Mentor Name

Month Day, Year

Covered but Still Exposed: Eligibility Rules, Cost Sharing and Who Pays the Facility Fee at a Hospital-Owned Clinic

In the first module I traced how a follow-up visit at our hospital-owned clinic now produces two bills, each with its own coinsurance. Whether those bills cause hardship depends less on the visit than on the patient's coverage. This paper examines the access and coverage rules that decide who pays the facility fee coinsurance in full, who is protected, and who falls through the gaps. It looks at traditional Medicare, supplemental coverage, the Medicare Savings Programs, Medicaid and the uninsured, and connects each rule to the patients who call our front desk.

Traditional Medicare and Its Missing Ceiling

Most of our older patients have traditional Medicare. After the annual Part B deductible, Medicare generally pays eighty percent of approved amounts for outpatient services and the beneficiary owes twenty percent coinsurance (Centers for Medicare & Medicaid Services, 2024). Unlike most private plans and Medicare Advantage plans, traditional Medicare has no annual out-of-pocket maximum. For a patient with a few visits a year, the facility fee coinsurance is an irritation. For a patient with heart failure, diabetes and kidney disease who visits several hospital-owned clinics each month, the added coinsurance on every facility fee accumulates without any ceiling.

Most beneficiaries in traditional Medicare fill that gap with supplemental coverage: a Medigap policy, retiree coverage from a former employer, or Medicaid. Each works differently, and the protection depends on which one a person has. A beneficiary with a comprehensive Medigap plan pays a premium but owes little at the point of care; a beneficiary with no supplement owes every twenty percent in full. The patients who call most upset are usually in the second group.

The gap is not evenly spread. Beneficiaries who turned sixty-five after leaving jobs without retiree benefits, and who could not afford or did not understand Medigap when they first enrolled, often face medical underwriting if they try to buy a policy later in many states. A decision made in the first months of Medicare eligibility can therefore determine exposure to facility fee coinsurance for years. Several of our patients described exactly that sequence.

The Medicare Savings Programs and the Take-Up Gap

Low-income beneficiaries can get help through the Medicare Savings Programs, which are administered by state Medicaid agencies and pay Medicare premiums and, for the lowest-income group, Medicare cost sharing as well. In principle, the poorest patients facing facility fee coinsurance should be protected. In practice, many who qualify are not enrolled. Kotb et al. (2025) analyzed national survey data and estimated that only about 57 percent of eligible beneficiaries were enrolled, with take-up ranging from about 42 percent in one state to 73 percent in another, and with enrolled beneficiaries more likely than unenrolled eligible beneficiaries to report the lowest incomes and assets. The pattern suggests that people just above the deepest poverty, and those who do not know the programs exist, are the most likely to miss out.

That finding describes several of our patients exactly. A retired school bus driver who lives on a modest pension and Social Security, with savings below the asset limit, had never heard of the program and had been paying facility fee coinsurance for a year. The rule did not exclude this patient; the application process and lack of information did.

Under Sixty-Five: Medicaid, Marketplace Plans and the Uninsured

Patients under sixty-five face a different set of rules. New Jersey expanded Medicaid, so adults with incomes up to the expansion threshold are eligible, and Medicaid generally covers the facility fee with little or no cost sharing. Above that threshold, marketplace and employer plans apply, and many have high deductibles under which a facility fee is paid entirely by the patient until the deductible is met. Adults who are uninsured, including many immigrants who are ineligible for Medicaid and marketplace subsidies because of their status, face the full charge, reduced only if the hospital applies its charity care or financial assistance policy.

The rules therefore expose three groups in particular: traditional Medicare beneficiaries without supplemental coverage, commercially insured patients with high deductibles, and the uninsured. The first group is concentrated among older patients with modest incomes who do not qualify for, or have not enrolled in, the savings programs.

Hospital financial assistance policies are the last layer of protection for these groups. Nonprofit hospitals are required to have written policies and to publicize them, but eligibility thresholds, application requirements and how actively staff offer them vary widely. Our clinic's front desk had never been trained to mention the policy, so patients who might have qualified paid their bills or let them go to collections.

What Site-Neutral Payment Would and Would Not Change

Policies that pay one rate for a service whether a hospital department or an independent office provides it, usually called site-neutral payment, would lower Medicare's payment and therefore the beneficiary's coinsurance for affected services. Lou et al. (2025) modeled three versions of the policy, from a narrow one worth roughly two hundred million dollars a year to a broad one worth more than seven billion, and found that beneficiaries grouped by age or by Medicaid eligibility would be affected in much the same way. In other words, site-neutral payment would reduce costs broadly but would not by itself target the groups most exposed. For those groups, enrollment in existing protections such as the savings programs, and hospital financial assistance policies that are easy to use, matter as much as payment reform.

For a nurse leader, the access lesson is practical. Our clinic now screens patients with traditional Medicare and no supplement for possible savings program eligibility and gives them the state application with help from our social worker. That step does not change national policy, but it closes a gap that the eligibility rules left open and the application process kept open.

Each group also needs a different remedy, which is why a single policy rarely closes every gap.

Naming the groups is the first step toward choosing remedies.

References

Centers for Medicare & Medicaid Services. (2024). Medicare & you 2025. U.S. Department of Health and Human Services. https://www.medicare.gov/publications/10050-medicare-and-you.pdf

Kotb, S., Su, A., & Sinaiko, A. D. (2025). Medicare Savings Program take-up estimates and profile of enrolled and unenrolled individuals. JAMA Network Open, 8(10), e2535408. https://doi.org/10.1001/jamanetworkopen.2025.35408

Lou, K. K., Linehan, K. E., da Fonte, L. N., Lai, P., & Buntin, M. B. (2025). Medicare site-neutral payment policies: Effects of proposals on hospitals and beneficiary groups. Health Affairs, 44(6), 668-676. https://doi.org/10.1377/hlthaff.2024.01501