What is the difference between Medicare and Medicaid?
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.