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Medicare And Medicaid What Are Some Recent Developments
A few months ago, the Beneficiary Enrollment Notification and Eligibility Simplification Act was signed into law. It eliminates the long waiting period, sometimes up to 7 months, for coverage for certain enrollees. Beginning in 2023, coverage for Medicare will being in the month after the participant enrolls.
Not long ago , a group of Democrats reintroduced legislation in the Senate to lower the age from 65 to 50 in order to qualify for Medicare benefits. If passed, this would mean millions more Americans would become eligible for Medicare. Proponents of the legislation contend that getting folks on Medicare could save lives and provide much-needed care. They point to the fact that many people dont have access to private insurance, and so care is delayed. That becomes both financially and physically costly down the road. Opponents, of course, point out the financial strain it would cause on the federal budget. Some also claim that this expanded healthcare might allow more folks to retire at a younger age, putting a strain on the workforce. Hospitals oppose the legislation, as Medicare reimbursement rates are much lower than what the hospital would receive from private insurance plans.
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Who Runs Medicare And Medicaid
The federal government runs the Medicare program. Each state runs its own Medicaid program. Thats why Medicare is basically the same all over the country, but Medicaid programs differ from state to state.
The Centers for Medicare and Medicaid Services, part of the federal government, runs the Medicare program. It also oversees each states Medicaid program to make sure it meets minimum federal standards.
Although each state designs and runs its own Medicaid program, all Medicaid programs must meet standards set by the federal government in order to get federal funds .
In order to make significant adjustments to their Medicaid programs, states must seek permission from the federal government via a waiver process.
Services That Medicare Does Not Provide
If Medicare does not cover a medical expense or service, a person may wish to take out a Medigap plan for supplemental coverage.
Private companies also offer Medigap plans. Depending on the individual plan, Medigap may cover:
- copayments
- deductibles
- care outside of the U.S.
If a person has a Medigap policy, Medicare will first pay their eligible portion. Afterward, Medigap will pay the rest.
To have a Medigap policy, a person must have both Medicare Parts A and B and pay a monthly premium.
Medigap policies do not cover prescription drugs, which a Part D plan covers.
An individual must be one of the following to be eligible for Medicare:
- age over 65 years
- age under 65 years and living with a disability
- any age with end stage renal disease or permanent kidney failure needing dialysis or transplant
They must also be:
- a U.S. citizen or permanent legal resident for 5 years continuously
- eligible for Social Security benefits with at least 10 years of contributing payment
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Qualifying For Both Medicare And Medicaid
Some seniors rely on Medicaid as well as Medicare benefits. In these cases, Medicaid helps Medicare beneficiaries pay for things that arent covered by Medicare, such as some personal care and nursing home care.
Medicare typically pays first for services that are covered by Medicare Part A or Part B. Medicaid can then help the beneficiary pay for costs like Medicare deductibles, coinsurance or copays.
Medicaid beneficiaries automatically qualify for Medicare Extra Help, which is a program that helps pay for Medicare prescription drug costs and makes prescription drugs much more affordable for beneficiaries. Medicaid also covers some prescription drugs that Medicare doesnt cover.
If someone is eligible for Medicare and Medicaid, they are sometimes referred to as dual-eligible.
How Much Does Medicare Part A Cost
When you use Medicare Part A, you have to pay for certain costs out of your own pocket. The biggest expense under Part A is the inpatient hospital deductible. For 2021, the deductible is $1,484. This is your share of costs for the first 60 days of Medicare-covered inpatient hospital care. After 60 days, your share will be $371 per day.
But the Part A deductible isnt like the deductible you might have with private insurance. With Original Medicare, you could pay the deductible more than once during a year which could happen if you go to the hospital more than once in a year, or if you need skilled nursing several times.
If these events are separated by more than 60 days, youll pay the deductible more than once.
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What Is The Advantage Of Medicaid
Medicaid provides critical access to comprehensive, cost-effective care for tens of millions. A wide body of research demonstrates that Medicaid provides critical access to comprehensive, cost-effective care for tens of millions of children and families, seniors, people with disabilities, and other adults.
Medicare Vs Medicaid: Eligibility
Medicare: Youre eligible once you turn 65, as long as youre a U.S. citizen or legal permanent resident. Medicare also covers younger people with disabilities and certain diseases, including end stage renal disease and Lou Gehrigs disease or amyotrophic lateral sclerosis . People with higher incomes pay larger premiums for certain parts of Medicare, but eligibility isnt limited by income.
Medicaid: Medicaid coverage is based on income. Medicaid is available in every state to those with incomes below the poverty line. Under the Affordable Care Act, most states have expanded Medicare eligibility to people with incomes up to 133% of the federal poverty line.
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Filling The Medicare Coverage Gaps
Many people worry about spending too much money on Medicare. The lack of a spending cap and prescription drugs are two reasons people often add additional coverage.
You have options in how you get your Medicare coverage: Original Medicare or Medicare Advantage. Original Medicare doesnt cover prescriptions. Most Medicare Advantage health plans and all Medicare prescription drug plans do offer prescription drug coverage. Medicare Advantage plans also offer additional benefits, coordination of benefits, and often more predictable costs. Therefore, many Medicare recipients join Medicare Advantage plans. However, many individuals prefer Original Medicare and enrollees can also enroll in standalone prescription drug plans, or buy Medicare Supplement insurance policies to fill gaps in coverage.
In addition to annual spending caps, both Medicare Advantage and Medigap plans help pay for the costs youd normally pay under Original Medicare:
- Part A and B deductibles
- Part B coinsurance
- Emergency coverage outside the United States
What Does Medicaid Cover For Adults
Mandatory benefits include services including inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services including prescription drugs, case management, physical therapy, and occupational therapy.
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What Are Dual Health Plans
Dual health plans are designed just for people who have both Medicaid and Medicare. Theyre a special type of Medicare Part C plan. Dual health plans combine hospital, medical and prescription drug coverage. Youll keep all your Medicaid benefits. Plus, you could get more benefits than with Original Medicare. And you could get it all with as low as a $0 plan premium.
View the “Do I Lose My Medicaid Benefits?” article.
Who Pays For Medicaid
Medicaid does not pay money to individuals but sends payments directly to healthcare providers.
States make these payments according to a fee-for-service agreement or through prepayment arrangements, such as health maintenance organizations . The federal government then reimburse each state for a percentage share of their Medicaid expenditures.
This Federal Medical Assistance Percentage changes each year and depends on the states average per capita income level.
The reimbursement rate begins at 50% and reaches 77% in 2020. Wealthier states receive a smaller share than states with less money.
In the states that chose to expand their coverage under the Affordable Care Act, more adults and families on low incomes are eligible with the new provision allowing enrolment at up to 138% of the FPL. In return, the federal government cover all expansion costs for the first 3 years and over 90% of the costs moving forward.
Medicare is a federal health insurance program that funds hospital and medical care for older people in the U.S. Some people with disabilities also benefit from Medicare.
The program consists of:
- Part A and Part B for hospital and medical insurance
- Part C and Part D that provide flexibility and prescription drugs
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Who Is Eligible For Medicaid
You may qualify for free or low-cost care through Medicaid based on income and family size.
In all states, Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states the program covers all low-income adults below a certain income level.
- First, find out if your state is expanding Medicaid and learn what that means for you.
- If your state is expanding Medicaid, use this chart to see what you may qualify for based on your income and family size.
Even if you were told you didn’t qualify for Medicaid in the past, you may qualify under the new rules. You can see if you qualify for Medicaid 2 ways:
- Visit your state’s Medicaid website. Use the drop-down menu at the top of this page to pick your state. You can apply right now and find out if you qualify. If you qualify, coverage can begin immediately.
- Fill out an application in the Health Insurance Marketplace. When you finish the application, we’ll tell you which programs you and your family qualify for. If it looks like anyone is eligible for Medicaid and/or CHIP, we’ll let the state agency know so you can enroll.
What Are My Coverage Options Under Medicare
Original Medicare coverage is the same in every state, including eligibility, benefits, and premiums. A Medicare beneficiary pays the same price for Medicare Part B, regardless of where the beneficiary lives .
But a significant portion of Medicares coverage is provided through private plans. The private plan options under Medicare including Medicare Part D , Medigap and Medicare Advantage vary considerably from one area to another in terms of which insurers offer coverage, the specific plan designs they offer, and the pricing. Most of the general regulations that apply to those plans are the same in every state. State regulations for Medigap plans do vary considerably, however. Federal rules do not require Medigap insurers to offer coverage to disabled enrollees under age 65, but the majority of the states have implemented their own rules to ensure at least some access to Medigap plans for these enrollees. You can click on a state on this map to see applicable Medigap rules.
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What Is The Advantage Of Having Medicaid
Medicaid provides critical access to comprehensive, cost-effective care for tens of millions. A wide body of research demonstrates that Medicaid provides critical access to comprehensive, cost-effective care for tens of millions of children and families, seniors, people with disabilities, and other adults.
Is Medicare Considered Welfare
Medicare is an insurance program while Medicaid is a social welfare program. Taxpayer funding provides Medicaid to eligible needy people in a manner similar to other social welfare programs like Temporary Assistance for Needy Families Women, Infants and Children and the Supplemental Nutrition Assistance Program.
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Dual Eligible Medicare Advantage Plans
Some private insurance carriers offer a type of Medicare Advantage plan thats called a special needs plan for enrollees with specific chronic conditions and for beneficiaries who are eligible for both Medicare and Medicaid.
If someone is dual-eligible, they may be able to enroll in a special needs plan for dual-eligibles if one is available where they live. These are often structured in a way that maximizes the benefit coverage of both Medicare and Medicaid.
What Are My Coverage Options Under Medicaid
Most states use private insurers to administer at least some Medicaid benefits. 39 states and D.C. covered at least some Medicaid beneficiaries through Managed Care Organizations as of mid 2019, but even more states use some form of managed care. If your state requires you to receive Medicaid benefits through an MCO, you have 90 days during which you can choose among the different plans available, but a plan will be chosen for you if you dont select one. This is called the choice period, and once it ends, you usually have to remain in your plan for 12 months.
Many states require adults to enroll in an MCO to receive Medicaid benefits as long as theyre not also eligible for Medicare. But if you have Medicare and Medicaid, then your Medicaid benefits are usually delivered through your states fee-for-service program. Some states use private insurers to deliver specific types of Medicaid benefits like long-term care while providing other Medicaid benefits using fee-for-service.
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What Is Medicare And How Does It Work
Medicare is a government health insurance program for people who are 65 and older or those with certain disabilities or diseases. According to the official Medicare website, individuals with Medicare may be eligible for supplementary health insurance through their employers or private insurance alternatives.
Eligibility requirements
The main Medicare requirement is age. When a person reaches age 65, they must enroll in Medicare although there are several exceptions or circumstances in which enrollment can be postponed. According to the American Association of Retired Persons, you have the ability to delay enrolling in Medicare until your job or coverage ends as long as you have health insurance from an employer for which you or your spouse actively works after you turn 65. Individuals have a special enrollment window when they turn 65, during which no late fees can be imposed.
According to the Center for Medicare Advocacy, individuals younger than 65 can qualify for Medicare if they have received Social Security disability benefits for two years or have end-stage renal disease or amyotrophic lateral sclerosis . Individuals with ESRD become eligible three months after a course of regular dialysis begins or after a kidney transplant. Individuals with ALS can apply as soon as they receive Social Security disability benefits. Dementia, mental illness, Alzheimer’s disease, and multiple sclerosis are other diseases that may make a person under 65 eligible for Medicare.
Effective Date Of Coverage
Once an individual is determined eligible for Medicaid, coverage is effective either on the date of application or the first day of the month of application. Benefits also may be covered retroactively for up to three months prior to the month of application, if the individual would have been eligible during that period had he or she applied. Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.
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Can You Have Both Medicare And Medicaid
In some cases, you can be eligible for both Medicaid and Medicare its referred to as dual eligible. With both Medicare and Medicaid coverage, the programs will cover practically all of your health expenses.
For dual eligibles, Medicare is the primary coverage and pays first. Medicaid pays second for anything that isnt covered. Medicare can cover your Part D prescription drugs while Medicaid may cover some drugs and other care not covered by Medicare.
Some states have a Medicare-Medicaid Plan which coordinates your Medicare and Medicaid benefits. Depending on your eligibility, you may qualify for a Dual Eligible Special Needs Plan with some state-covered costs.
Just because youre eligible for one doesnt mean you qualify for the other. Medicare status is determined by age or disability while Medicaid status is determined by income, says Dodge. It is important to check both since you may qualify for better benefits and reduced out-of-pocket expenses if you do.
How Are Medicaid And Medicare Different
In the healthcare industry, the acronym LASA, which stands for look-alike-sound-alike is used when referring to medications. When it comes to federal programs, Medicaid and Medicare, in written form, look alike and they do sound alike but work very differently.
Both Medicare and Medicaid were started in 1965 under Lyndon B. Johnsons administration in response to the inability of older and low-income people to purchase private insurance. Medicaid is an assistance program, funded federally and at the state level, that provides coverage for health care to low-income individuals regardless of age. It is governed federally with each state administering its own plan, which can vary from one state to the next. Medicare is a federal insurance program that provides health coverage for people aged 65 and over or to those under age 65 with a severe disability such as end-stage renal disease or Lou Gehrigs disease, also known as ALS-amyotrophic lateral sclerosis. Dependents are not typically covered.
Though basic differences are covered here, there is much more information to know regarding both plans, so research is encouraged before you hit the age of eligibility for Medicare to determine which Medicare plan may be right for you. Medicaid plans and coverage differ from state to state, and sometimes county to county. We would be happy to answer any questions you have about your potential eligibility for either program. Please contact our office at 814-209-4699.
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