Medicare and Medicaid are healthcare programs that are supported by the government and cater to different sets of individuals with varying eligibility criteria. There may be cases where a person could be eligible for both programs. It is essential to comprehend the disparities between Medicare and Medicaid and their functionality. This understanding can help an individual in availing all the benefits entitled to them, provided they meet the eligibility criteria for either or both programs.
Medicare Coverage Key Takeaways
Medicare is a government-run healthcare program that is divided into “parts.” Part A covers hospital insurance, while Part B covers outpatient services and is also called medical insurance. Part A and B together combine what is called Original Medicare.
On the other hand, Medicare Advantage, or Medicare Part C, is a single plan that combines Part A and B and covers everything in Original Medicare, along with additional benefits offered by private insurers. Eligibility for Medicare is open to individuals who are U.S. citizens or permanent residents aged 65 and above or those under 65 with specific disabilities, on dialysis, or who have had a kidney transplant. If you are eligible for Social Security benefits, you will also be eligible to get Medicare coverage in most cases.
What Medicare Will Cover?
Hospital insurance, also known as Medicare Part A, provides coverage for various services including inpatient hospital care, hospice care, skilled nursing facility care, and some home healthcare services. Semi-private rooms, meals, and other hospital services and supplies are covered during hospitalization. Hospice care offers pain management and emotional support for terminally ill patients. Skilled nursing facility care includes therapies like physical and occupational therapy. To be eligible for Medicare Part A, you need to be at least 65 years old and have paid into the Medicare system through payroll taxes, or have a disability or ESRD. However, Medicare Part A does not cover all expenses and additional coverage can be purchased through Medicare Part B, Part D, or private insurance.
Part B, on the other hand, is typically a premium-based coverage that is designed to cover medical services and equipment that are not covered by Part A.
Medicare Part B covers a variety of medical services and equipment. This includes visits to primary care physicians and specialists, preventive services like annual wellness visits and certain cancer screenings, laboratory tests like blood tests and diagnostic imaging services, and medical equipment like wheelchairs, walkers, and hospital beds. It also covers prosthetic and orthotic devices. However, it’s important to note that Part B does not cover everything. For example, it generally does not cover long-term care or custodial care services, such as those provided in a nursing home. Additionally, it typically does not cover services that are considered experimental or investigational.
To enroll in Part B, beneficiaries must pay a monthly premium. The amount of the premium varies depending on factors such as income and whether the individual is already receiving Social Security benefits. For most people, the monthly premium is currently $164.90, but it can be higher or lower depending on specific circumstances. Beneficiaries are also responsible for paying coinsurance or copayment for each service they receive. This means that they will pay a certain percentage of the cost of each service, with Medicare picking up the rest.
Medicare Part C, also known as Medicare Advantage, is an alternative to Original Medicare that is offered by private insurance companies that contract with Medicare. Medicare Advantage plans provide the same benefits as Original Medicare but may offer additional coverage such as prescription drug coverage, vision, and dental coverage. However, Medicare Advantage plans require beneficiaries to see doctors and hospitals within the plan’s network to receive coverage. The cost-sharing for Medicare Advantage plans is different from Original Medicare and can include a monthly premium, yearly deductible, copayments, and/or coinsurance.
Medicare Part D is a federal program that provides prescription drug coverage to people enrolled in Original Medicare or Medicare Advantage plans that don’t already include drug coverage. Private insurance companies that contract with Medicare offer Part D coverage. Part D plans typically cover a wide range of prescription drugs, but the specific drugs covered and the costs, such as premiums and copayments, can vary between plans. Enrolling in Part D is voluntary, but there may be penalties if you don’t enroll when you’re first eligible. The annual enrollment period is from October 15 to December 7, and you can choose a plan offered in your area or make changes to your plan during this period.
How To Get Medicare Coverage?
Medicare has several enrollment periods, depending on the type of coverage you need and your situation. The Initial Enrollment Period (IEP) is the seven months surrounding your 65th birthday (three months before and three months after you are 65), during which you can enroll in Original Medicare (Parts A and B). The Annual Enrollment Period (AEP) is from October 15 to December 7 each year, during which you can make changes to your Medicare coverage, including enrolling in a Medicare Advantage or Part D plan. The General Enrollment Period (GEP) is from January 1 to March 31 each year for those who didn’t enroll during their IEP. Finally, there’s the Special Enrollment Period (SEP), which occurs outside of regular enrollment periods and can be triggered by certain life events. It’s essential to follow the rules and deadlines for each enrollment period to avoid penalties, and some periods may not be available based on your circumstances.
Medicaid Coverage Key Takeaways
Medicaid is a program that is jointly administered by the federal and state governments with the goal of ensuring access to healthcare for individuals with low incomes. The program offers health coverage for a range of people, including families and children, pregnant women, the elderly, individuals with disabilities, and those with limited financial resources.
Medicaid Coverage
Federal guidelines require that certain benefits be included in all plans across all states, such as hospital stays, outpatient hospital services, laboratory and X-ray services, family planning services, nursing facility services, home health services, doctor visits, and transportation to medical care. Additionally, states have the option to offer additional benefits, such as prescription drugs, physical therapy, occupational therapy, speech, hearing, and language disorder services, respiratory care services, optometry services, and dental services.
I am Eligible for Medicaid if I Have Medicare Coverage?
Yes, you can be. Dual eligibility enables a person to enroll in both Medicare and Medicaid by meeting the eligibility criteria of both programs. Meeting the requirements of Medicare and Medicaid is necessary to qualify for dual eligibility. When a person is dual-eligible, both Medicare and Medicaid collaborate to cover their medical expenses. Apart from this, dual-eligible individuals may also be eligible for additional programs such as a dual special needs program, which provides extra benefits such as over-the-counter and prescription drug coverage, home delivery, grocery coverage, and transportation.
Typically, individuals aged 65 and above are eligible for Medicare Part A and Part B coverage. However, those under 65 may also qualify for Medicare if they have certain disabilities, end-stage renal disease, or amyotrophic lateral sclerosis (ALS). Medicaid eligibility is dependent on the eligibility requirements of the state in which the person resides. Although states are required to cover specific groups such as low-income families, individuals receiving Supplemental Security Income (SSI), qualified pregnant individuals, and qualified children.
Main Differences Between Medicare and Medicaid
Medicare is an insurance program primarily designed for people over the age of 65, although it does provide coverage for some younger people with certain disabilities. Medicaid, on the other hand, is an assistance program that covers medical costs for individuals of all ages who come from lower income brackets.
Medicare is a federal program that operates under federal guidelines, while Medicaid is a state program that also operates under federal guidelines. In order to receive Medicare benefits, individuals must enroll in Social Security. For Medicaid, enrollment must be done through a local state agency.
Thomas M. Brzezinski is one of the founding partners of WMAG William & Michael Advisor Group LLC and Jersey Insurance Solutions. He has been involved in the insurance industry for over ten years and specializes in developing client relationships that last a lifetime.
Craig W. Hansen is an insurance professional and co-founder of William & Michael Advisor Group LLC and Jersey Insurance Solutions. Craig has served his clients in many facets of the insurance industry, always with the same goal: excellence in service while building solid, long-term, lasting relationships. With over a decade of experience in the insurance benefits industry, Craig’s clients know they can call on him anytime and receive platinum service with a smile.
