What is Medicare and Medicaid?

During your lifetime you have probably had several different companies that provided you medical insurance. If your insurance was provided by your employer, often they determined what insurance policies you had with limited options.

Fast forward to your retirement years and now you have to determine what type of a plan is best for you. Most have heard the terms Medicare and Medicaid, but unless you learned about both while caring for a loved one, you may feel extremely overwhelmed by the options available now that it’s time to plan for yourself.

 

Understanding the Differences Between Medicare and Medicaid

Medicare and Medicaid are two separate, government-run programs. They are operated and funded by different parts of the government and primarily serve different groups. Established in 1965 and funded by taxpayers, these two programs have similar-sounding names, which can cause confusion about how they work and the coverage they provide.

• Medicare is a federal program that provides health coverage if you are 65+ or under 65 and have a 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 or dually eligible, you can have both. They will work together to provide you with health coverage and lower your costs.

Medicare and Medicaid are both health insurance programs administered by the government, but there are differences in covered services and cost-sharing.

 

Medicare

Medicare is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions. A federal agency called the Centers for Medicare & Medicaid Services runs Medicare. Because it’s a federal program, Medicare has set standards for costs and coverage. This means a person’s Medicare coverage will be the same no matter what state they live in. Original Medicare (Parts A and B) benefits are administered by the government. Part A is hospital services and Part B is medical care. Part C and D benefits are administered by private insurance companies.

Medicare-related bills are paid from two trust funds held by the U.S. Treasury. Different sources, including payroll taxes and funds that Congress authorizes, fund the trust funds. People with Medicare pay part of the costs through things like monthly premiums for medical and drug coverage, deductibles and coinsurance.

 

What Are The 4 Parts of Medicare?

• Medicare Part A and Part B, also known as Original Medicare, cover most inpatient and outpatient medical needs.
• Part C, also known as Medicare Advantage, and Part D, prescription drug coverage are available through private insurers and provide coverage beyond what is included with Part A and Part B.

Medicare Part A is your hospitalization insurance. Medicare Part A includes:

• Hospital stays, semi-private rooms, up to 60 days
• Hospital meals
• Nursing services
• Intensive care services
• Drugs, medical supplies, and equipment used on the premises
• Lab tests and X-rays taken while hospitalized
• Surgery and recovery costs
• Rehabilitation and therapy services
• Part-time home nursing care

Medicare Part B provides for outpatient medical needs. Medicare Part B includes:

• Routine doctor visits
• Tests, screenings, and X-rays
• Flu shots and other vaccinations
• Necessary medical supplies
• Outpatient mental health care
• Medically necessary preventive care

You can add more coverage to your Original Medicare with Part C and Part D plans, which are offered through private insurers. You can add one or the other, or you can combine both Part C and Part D as a Medicare Advantage prescription drug plan. Part C, or Medicare Advantage, offers Part A and Part B coverage and may offer benefits including:

• Prescription drug coverage when combined with Part D
• Routine dental care including cleanings, X-rays, and dentures
• Routine vision care including contacts and glasses
• Routine hearing care including hearing aids
• Fitness benefits including exercise classes

Part D plans only offer prescription drug coverage. These plans are a good option when you just need drug coverage added to your Original Medicare.

 

Medicaid

Medicaid is a joint federal and state program that helps cover medical costs for some people with limited income and resources. Medicaid offers benefits not normally covered by Medicare, like nursing home care and personal care services. The rules around who’s eligible for Medicaid are different in each state.

Medicaid offers benefits that Medicare doesn’t normally cover, like nursing home care and personal care services. People with Medicaid usually don’t pay anything for covered medical expenses but may owe a small co-payment for some items or services.

 

Qualifying for Medicaid

You must meet your state’s rules for your income and resources, and other rules, such as being a resident of the state.

You might be able to get Medicaid if you meet your state’s resource limit, but your income is too high to qualify. Some states let you “spend down” the amount of your income that’s above the state’s Medicaid limit. You do this by paying non-covered medical expenses and cost sharing until your income is lowered to a level that qualifies you for Medicaid.

 

What Medicaid Helps Pay For

If you have Medicare and qualify for full Medicaid coverage:

• Your state will pay your Medicare Part B Medical Insurance monthly premiums.
• Depending on the level of Medicaid you qualify for, your state might pay for:
  • Your share of Medicare costs, like deductibles, coinsurance, and copayments
  • Part A, hospital insurance premiums, if you have to pay a premium for that coverage.
  • You’ll automatically get extra help with your drug costs.
  • Medicaid may pay for other drugs and services that Medicare doesn’t cover.

Medicaid Mandated Benefits

Medicaid benefits vary by state, but the Federal government mandates coverage for a variety of services, including:

• Inpatient hospital services
• Outpatient hospital services
• EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
• Nursing facility services
• Home health services
• Physician services
• Rural health clinic services
• Federally qualified health center services
• Laboratory and X-ray services
• Family planning services
• Certified family nurse practitioner services
• Transportation to medical care
• Tobacco cessation counseling

 

People who have both Medicare & Medicaid

People who have both Medicare and full Medicaid coverage are “dually eligible.” Medicare pays first when you’re dual eligible and you get Medicare-covered services. Medicaid pays last, after Medicare and any other health insurance you have.

If you’re dually eligible, Medicare covers your prescription drugs. You’ll automatically be enrolled in a Medicare drug plan that will cover your drug costs instead of Medicaid. Medicaid may still cover some drugs that Medicare doesn’t cover.

 

It’s Important to Know Your Options

Gaining a clear understanding of Medicare and Medicaid is essential for making informed healthcare decisions. By knowing what each program offers and who qualifies, you can ensure that you or your loved ones receive the appropriate coverage and potentially save on healthcare expenses. Take the time to explore your options and stay informed about these vital programs.

The information provided are the basic concepts for both Medicare and Medicaid. The Ohio Masonic Communities strongly encourages you to contact Medicare at the number below or your local Medicaid office to determine what fits your specific needs.

Please call 1-800-MEDICARE or contact your local Medicaid office to learn more about Medicare and Medicaid costs and coverage.

 

 

If you or a loved one has additional questions about Medicare or Medicaid, The Ohio Masonic Communities is a great resource. With three senior living communities across the state of Ohio – Browning Masonic Community in Waterville, Ohio, Springfield Masonic Community in Springfield, Ohio, and Western Reserve Masonic Community in Medina, Ohio – each offers premier living options with exceptional experiences so residents can live their best lives. If you are interested in learning more about one of our communities, give us a call at 1-877-881-1623. We will be happy to answer all your questions and be a trusted resource in the search for the right community for you!