Medicare and Medicaid Explained
Understanding Medicare v. Medicaid
Medicare and Medicaid play different, equally important roles in providing public funding for health care. According to Medicare.gov, “Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities and people with End-Stage Renal Disease.” Meanwhile, Medicaid provides assistance for low-income seniors and other disadvantaged populations. According to Medicaid.gov, “Medicaid provides health coverage to more than 4.6 million low-income seniors, nearly all of whom are also enrolled in Medicare…in total, 8.3 million people are “dually eligible” and enrolled in both Medicaid and Medicare.”
After a medically necessary inpatient hospital stay of at least three full days, Medicare will cover short-term skilled nursing care related to a hospitalization for up to 100 days if your doctor recommends it. (After the first 20 days in skilled nursing care, patients are responsible for a co-pay of $167.50 per day.)
Once rehabilitation is complete, Medicaid can help pay for any necessary ongoing care. Medicaid can also help pay for any costs that Medicare doesn’t cover during the initial short-term stay.
Medicare Benefits
Medicare has four components:
Part A, Hospital Insurance: This helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), home health care and hospice care.
Part B, Medical Insurance: This helps pay for services provided by doctors and other healthcare providers, outpatient care, many preventive care services, durable medical equipment and some home health care expenses.
Part C, Medicare Advantage: These plans are available in many areas. People with Medicare Parts A and B can choose to receive all of their health care services, including Part D prescription drugs if a Medicare Advantage Prescription Drug Plan (MAPD) is selected, through one of these provider organizations under Part C.
Part D, Prescription Drug Coverage: This helps pay for prescription medications.
It’s important to realize that Medicare covers only short-term, non-custodial care. This means you cannot use Medicare to cover long-term nursing home stays or assisted living. Medicare covers medically necessary skilled care at a nursing home if you need short-term skilled care for an illness or injury and you meet certain conditions.
To get more detailed information about Medicare, read “Medicare & You” (Publication No. CMS-10050). To receive a copy, call the Medicare toll-free number, 1-800-MEDICARE (1-800-633-4227), or go to: www.medicare.gov/publications.
Source: Medicare & You, CMS Product No. 10050, November 2017, www.medicare.gov/sites/default/files/2018-07/10050-medicare-and-you.pdf
Medicaid Benefits
The benefits covered for the elderly through Medicaid are different in each state, but certain benefits are covered in every Medicaid program. Mandatory Medicaid benefits required by federal law include:
Inpatient and outpatient hospital services
Nursing facility and home health services
Early and periodic screening, diagnostic and testing services
Transportation to medical care
Physician, laboratory and X-ray services
Rural health clinic and federally qualified health center services
Click here to learn more about your state Medicaid program.
Medicare Eligibility
Medicaid eligibility varies by state, but the federal government requires each state to cover certain populations. People with disabilities are eligible in every state. In some states, people with disabilities qualify automatically if they get Supplemental Security Income (SSI) benefits. Seniors who do not have disabilities, but are looking to finance long-term care with Medicaid may need to show both that care is needed and that their income and savings will not cover the cost of care.
What are “buy-ins?”
Some states also have “buy-in” programs that allow people with disabilities with incomes above regular Medicaid limits to enroll in the Medicaid program.
Affordable Care Act
In states that participate in the Affordable Care Act’s expansion of Medicaid, Medicaid may cover low-income adults who have disabilities but don’t meet SSI disability requirements and other people whose income is below 133% of the federal poverty level. The Medicaid program continues to move toward providing more community-based care options as an alternative to nursing homes.
Home and Community-based Services
Home and community-based services (HCBS) allow Medicaid beneficiaries to get services at home or in assisted living communities. Seniors and younger adults with disabilities may be eligible for HCBS programs. Each state can create its own HCBS waiver programs to serve its Medicaid recipients.
Money Follows the Person: What Does this Mean?
The “Money Follows the Person” Rebalancing Demonstration Program (MFP) helps states rebalance their long-term care systems by transitioning Medicaid recipients from institutional care to home- and community-based care. Forty-three states and the District of Columbia have implemented MFP programs, and as of the end of 2016, those programs have helped more than 75,000 people return to their homes and communities for care.
People who live in an institution for more than 90 consecutive days are eligible for the MFP program. Note that the number of days spent in short-term rehabilitative care in an institution doesn’t count toward the 90- day total.
The stated goals of the MFP program are as follows:
Eliminate barriers in state law, state Medicaid plans and state budgets that restrict the use of Medicaid funds to let people get long-term care in the settings of their choice.
Increase the use of home and community-based services (HCBS) and reduce the use of institutionally based services.
Put procedures in place to provide quality assurance and improve HCBS.
Strengthen the ability of Medicaid programs to provide HCBS to people who choose to transition out of institutions.
States participating in MFP include: AL, AR, CA, CO, CT, DE, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, VA, VT, WA, WI, WV and the District of Columbia.