Medicare and Medicaid: What You Need to Know
Are you overwhelmed by the complexities of healthcare insurance, confusing medical terms, and high medical costs? You’re not alone. Deciphering healthcare plans can be a daunting task, leaving many in need of guidance on coverage details and access to essential care. This uncertainty can cause delays in seeking treatment, ultimately affecting long-term health outcomes. Luckily, government programs such as Medicaid and Medicare offer relief by providing coverage for low-income individuals, families, and seniors, helping alleviate financial strain. If you’ve ever hoped for a simplified explanation of these programs, you’re in the right place with our blog!
Understanding Medicare vs. Medicaid
Medicare and Medicaid are both government programs that provide health coverage to individuals in need, but how do they differ? Let’s look at each program to learn more about coverage and benefits.
Who is Eligible for Medicare?
Medicare is a government-funded program created to provide affordable healthcare access, lessen financial strains on services, and improve health outcomes for individuals aged 65 and older. Beyond seniors, Medicare also extends coverage to select groups of younger individuals with disabilities and certain medical conditions.
Generally, Medicare is for people 65 or older. You may be eligible for Medicare earlier if you have a disability, End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant), or ALS (also called Lou Gehrig’s disease). [1]
Medicare has Four Parts [2]:
- Part A (Hospital Insurance) covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care. Part A typically does not require a premium if you or your spouse paid Medicare taxes while working.
- Part B (Medical Insurance) covers outpatient care, services from physicians and other healthcare providers, durable medical equipment, and some preventative screenings and services. Individuals usually pay a monthly premium for Part B that is based on their annual income.
- Part C (Medicare Advantage) includes coverage from Part A and Part B, and can also include other benefits such as vision, dental, and wellness services. Medicare Advantage plans are offered through private insurance carriers and may have different coverage options and costs based on service areas.
- Part D (Prescription Drug Coverage) covers a portion of prescription drug costs through private insurance plans. Individuals pay a monthly premium for Part D. Coverage options, copays, and co-insurance may vary depending on the plan.
What is Medicaid?
Medicaid is a joint federal and state program designed to provide health coverage to low-income individuals and families. By ensuring access to necessary care, Medicaid supports vulnerable populations, including children, those pregnant, the elderly, and people with disabilities.
You may qualify for free or low-cost health care through Medicaid based on your income and family size. Eligibility rules differ among states.
In all states, Medicaid gives health coverage to some individuals and families, including children, parents, those who are pregnant, seniors with certain incomes, and people with disabilities. Some states have expanded their Medicaid programs to cover other adults below a certain income level.[3]
The services covered by Medicaid vary by state, but generally can include: [4]:
- Inpatient and Outpatient Hospital Services: Medicaid covers necessary hospital stays and outpatient services.
- Physician Services: Medicaid helps cover regular doctor visits and specialist care appointments.
- Preventative Services: Medicaid helps cover vaccinations, screenings, and wellness checks.
- Long-Term Care: Medicaid helps cover nursing home care and community-based services for individuals who require long-term care.
- Mental Health Services: Medicaid helps cover mental health treatment, like therapy.
- Prescription Drug Coverage: Medicaid helps cover prescription medications.
- Dental and Vision Services: In certain states, Medicaid helps cover dental and vision services.
Can You Have Medicare and Medicaid?
You may be wondering if you can have both Medicare and Medicaid? The answer is yes – you can have both. Through dual eligibility and enrollment, you can access and utilize the benefits of both programs. [5].
Known as “concurrent enrollment” or “dual enrollment,” this arrangement offers numerous advantages, including:
- Enhanced Coverage
- Reduced Out-of-Pocket Expenses
- Expanded Access to Services
How, exactly, do the two programs work together? Medicare and Medicaid work together as your primary and secondary healthcare coverage. Medicare serves as your primary healthcare coverage, while Medicaid acts as secondary coverage. Medicare typically pays for services first, with Medicaid stepping in to cover any additional costs that Medicare may not cover. This secondary support is especially helpful for covering copayments, coinsurance, and deductibles that Medicare may not fully cover [5].
Who is Eligible for Both Medicare and Medicaid?
To be eligible for dual enrollment, you must meet the criteria for both Medicare and Medicaid. This includes being either 65 years old or older, or under 65 with a qualifying disability (and receiving Social Security Disability Insurance for at least 24 months). [6]
Additionally, applicants must meet their state’s income limits for Medicaid, have limited assets as defined by the state, be a resident of the state in which they are applying, be a U.S. citizen or qualified legal resident, and be enrolled in Medicare Parts A and/or B.
How to Apply for Medicare and Medicaid
After understanding the eligibility criteria and benefits of Medicare and Medicaid, it is important to know how to apply for these programs.
To apply to Medicare [7], first, determine the enrollment period suitable for you. The initial enrollment period begins three months before your 65th birthday and extends three months after it. Special enrollment periods might be available through your or your spouse’s Employee Health Plan as well.
After identifying the appropriate enrollment period, gather all necessary information and documents, such as your social security number, birth certificate (or proof of age), and employment details if relevant. Choose your preferred application method – online through the Social Security Administration website, over the phone, or in person at your local Social Security office. Once your application is complete, you will receive confirmation of enrollment.
To apply for Medicaid [8], ensure you have gathered the required documentation including proof of income, bank statements, social security numbers, and identification.Then, visit your state’s Medicaid program website to submit your application. Depending on your state, you may be able to apply online, by phone, or in person. Eligibility results are typically received within two weeks of applying.