What is the dif­fer­ence be­tween Medi­care and Med­i­caid?

Record Observer - - SENIOR SATELLITE - By MIKE ZIM­MER

Medi­care and Med­i­caid are two dif­fer­ent gov­ern­ment-run so­cial in­surance pro­grams that were cre­ated in 1965 in re­sponse to the in­abil­ity of older and low­in­come Amer­i­cans to buy pri­vate health in­surance.

Med­i­caid is not the same as Medi­care:

• Medi­care is a fed­eral pro­gram that pro­vides health cov­er­age if you are 65 or older or have a se­vere dis­abil­ity, no mat­ter your in­come.

• Med­i­caid is a state and fed­eral pro­gram that pro­vides health cov­er­age if you have a very low in­come.

• If you are el­i­gi­ble for both Medi­care and Med­i­caid (dual el­i­gi­ble), you can have both. Medi­care and Med­i­caid will work to­gether to pro­vide you with health cov­er­age.

How does Med­i­caid work with Medi­care to cover my health care costs?

All states of­fer a va­ri­ety of Med­i­caid pro­grams and sev­eral can help peo­ple with Medi­care. If you qual­ify for a Med­i­caid pro­gram, Med­i­caid can help pay for costs and ser­vices that Medi­care does not cover. Medi­care is the pri­mary payer and Med­i­caid pays se­cond.

For ser­vices that both Medi­care and Med­i­caid can cover (such as doc­tors’ vis­its, hospi­tal care, home care and skilled nurs­ing fa­cil­ity care), Medi­care will pay first and Med­i­caid will pay se­cond, by cov­er­ing your re­main­ing costs, such as the Medi­care coin­sur­ances and co­pay­ments. In many cases if you have Med­i­caid, you will au­to­mat­i­cally be en­rolled in a Medi­care Sav­ings Pro­gram (MSP). Also run through Med­i­caid, MSPs will of­fer ad­di­tional as­sis­tance by pay­ing your Medi­care Part B pre­mium. De­pend­ing on your in­come, you may qual­ify for one MSP called Qual­i­fied Medi­care Ben­e­fi­ciary (QMB) which will pay for your Medi­care de­ductibles, coin­sur­ances and co­pay­ments. You will need to meet the guide­lines that your Med­i­caid pri­vate health plan is de­signed to work with. But even if you are re­quired to en­roll in a Med­i­caid pri­vate health plan in your state, you can­not be re­quired to en­roll in a Medi­care Ad­van­tage Plan.

Check with your lo­cal Med­i­caid of­fice to learn more about your health plan op­tions. To find out the ex­act Med­i­caid pro­grams you may be el­i­gi­ble for, you should con­tact your lo­cal Med­i­caid of­fice and speak to a coun­selor. Fi­nan­cial eli­gi­bil­ity guide­lines and cov­ered ser­vices vary greatly from state to state and from pro­gram to pro­gram. Be aware that you may be able to have higher in­come than gen­eral eli­gi­bil­ity guide­lines sug­gest be­cause cer­tain in­come may not be counted, or you may be able to qual­ify an­other way — for ex­am­ple, by spend­ing down your in­come on med­i­cal ex­penses.

Which Med­i­caid pro­grams might I qual­ify for if I have Medi­care?

Whether you qual­ify for a Med­i­caid pro­gram will de­pend on:

• your in­come (money you take in, for ex­am­ple, from So­cial Se­cu­rity pay­ments or wages that you earn);

• your as­sets (re­sources such as check­ing ac­counts, stocks and some prop­erty); and

• if you need long-term care, whether you meet your state’s func­tional eli­gi­bil­ity or level-of­care cri­te­ria stan­dards for as­sess­ing your need for help with ac­tiv­i­ties of daily liv­ing (for ex­am­ple, toi­let­ing, bathing, dress­ing) and your need for nurs­ing care. Each state sets its own stan­dards. Med­i­caid pro­grams can help pay for Medi­care’s costs and for ser­vices that Medi­care does not cover.

In gen­eral, peo­ple with Medi­care who have low in­come may qual­ify for one of the fol­low­ing:

1. Med­i­caid for peo­ple who are over 65, blind or have a dis­abil­ity and do NOT need long-term care.

If you are over 65, blind or have a dis­abil­ity, do not have a press­ing need for long-term care and meet the fi­nan­cial re­quire­ments, you may qual­ify for Med­i­caid cov­er­age of a broad range of health ser vices, in­clud­ing doc­tors’ vis­its, hospi­tal care, and med­i­cal equip­ment. 2. Nurs­ing Fa­cil­ity Med­i­caid If you have lim­ited in­come and meet your state’s level-of-care or func­tional eli­gi­bil­ity cri­te­ria, Nurs­ing Fa­cil­ity Med­i­caid may pay for a stay in a skilled nurs­ing fa­cil­ity (nurs­ing home). Nurs­ing Fa­cil­ity Med­i­caid cov­ers ser­vices such as room and board, nurs­ing care, per­sonal care and ther­apy ser­vices, States de­ter­mine their own func­tional eli­gi­bil­ity stan­dards, but usu­ally your state will as­sess your need for help with ac­tiv­i­ties of daily liv­ing (for ex­am­ple, toi­let­ing, bathing, dress­ing) and your need for nurs­ing care. All states have Nurs­ing Fa­cil­ity Med­i­caid pro­grams.

3. Med­i­caid Waiver Pro­grams for long-term care in your home or com­mu­nity

If you have lim­ited in­come and meet your state’s level-of-care or func­tional eli­gi­bil­ity cri­te­ria, a Med­i­caid home and com­mu­ni­ty­based ser­vice (HCBS) waiver pro­gram (or pro­grams) may cover long-term care ser­vices in your home or a com­mu­nity set­ting (for ex­am­ple, in an as­sisted liv­ing fa­cil­ity). States de­ter­mine their own func­tional eli­gi­bil­ity stan­dards, but usu­ally your state will as­sess your need for help with ac­tiv­i­ties of daily liv­ing (for ex­am­ple, toi­let­ing, bathing, dress­ing) and your need for nurs­ing care.

Mike Zim­mer is Pres­i­dent of Bay State In­surance Agency Ltd. in Cen­tre­ville. He is avail­able to an­swer your ques­tions or speak to your groups re­gard­ing Medi­care, Medi­care Ad­van­tage, Medi­care Sup­ple­ments and Medi­care Part D (Pre­scrip­tion Plans) He may be reached at 410-758-1680.

MIKE ZIM­MER

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