Medicare vs Medicaid: Do You Know The Difference?

By CarePatrol of Baltimore

If you’re not sure what the distinction is between Medicare and Medicaid, you’re certainly not alone. While both are government programs that help pay for healthcare, the cost, benefits and eligibility requirements are often very different. Below is a summary of each programs benefits. Also, see what happens when you can qualify for both.

Medicare

Medicare is a federally funded program offered to most U.S. citizens and permanent legal residents who have lived in the country for five years or more. Participants must be age 65 or older. If under that age, you can still qualify if you’ve received 24 month of Social Security disability benefits from the Railroad Retirement Board (RRB), have permanent kidney failure and need routine dialysis (or a kidney transplant), or have Lou Gehrig’s disease (amyotrophic lateral sclerosis). Because these specifications are rare, most recipients are seniors.

Medicare Part A is a free program that covers most medically necessary services and supplies. Generally, it covers hospital care, skilled nursing and nursing home care, hospice, and home health services. To qualify, you or your spouse must have worked at least 10 years and paid Medicare payroll taxes while working.

Part B covers preventative care and additional services so it has a monthly premium. If you need prescription drug coverage, it’s best to enroll in a Part D plan or a Medicare Advantage plan (Part C). These are offered by private Medicare-care approved insurance companies, and their costs differ.

If you’re already participating in Part A and need drug coverage, enroll in a stand-alone Part D program. If you’re already in a Medicare Advantage Plan, there is probably a drug coverage option you can add to your current coverage. There could be an additional monthly premium, on top of your Part B premium, for Advantage Plans, so be sure to check rates.

If you’re still working and become qualified for Medicare, you can drop your employer’s coverage and join Medicare if desired. But you don’t have to if the coverage you currently have is better or more affordable. If you work for a small business, and your company has fewer than 20 employees, it’s recommended you enroll in Medicare Part B. Some companies even require it. In those cases, Medicare becomes your primary coverage, and the employer plan becomes secondary. (This helps the company save money).

If your spouse is not yet eligible, it’s best to stick with your current employer coverage to ensure they are also covered. If you decide to enroll later when you retire, you’ll be given a special window of eight months to complete enrollment in a Medicare program.

When choosing the right plan, you should always speak to your doctor about the kind of healthcare services they think you’ll need in the future. You can use this information to figure out which plan offers the most value.

Medicaid

Medicaid is a jointly-funded program by the government and the state that supports low-income individuals and families with covering medical and long-term custodial care. It is not limited to older adults.

Medicaid has some of the same Benefits are Medicare, such as inpatient and outpatient hospital care. However, some states offer additional service coverage. In Maryland, for example, Medicaid covers prescription drugs and very limited dental coverage. For adults, dental is available for pregnant mothers and for people in the Rare and Expensive Case Management (REM) Program. Otherwise, stand-alone dentals programs are offered.

Though states differ, all state programs offer basic healthcare service coverage, which includes nursing facility care, home healthcare, doctor services, rural health clinic care, x-rays and labwork, family planning, midwife services, pediatric and family nurse practioner care and tobacco cessation services for pregnant mothers.

Eligibility for Medicaid is means-based, and the program has strict requirements that vary from state to state. In Maryland, an adult individual cannot make more than $16,394 per year, and an adult couple cannot make more than $22,108 per year. All enrollment is online through MarylandHealthConnection. When you access your applicant, it will indicate whether or not you are eligible.

Qualifying for Both

Low-income seniors may qualify for both Medicare and Medicaid and are known as “dual eligible.” Dual eligible participants can take advantage of both program’s benefits, according to their specific needs. Medicare is usually used as the primary program, with Medicaid offering supplemental coverage. You can be a full- or partial-benefit recipient. Unfortunately, navigating this process can very complex and confusing.

Since dual eligible individuals are often the poorest and sickest older adults, there was been a more recent effort to better integrate the two programs. For example, the Affordable Care Act established a type of D-SNP (Special Needs Plan), called a Fully Integrated Dual Eligible SNP. The care is provided through a single managed care organization. This may change, depending on what happens with the Affordable Care Act in the coming years.