Navigating the healthcare system as an older adult can be very confusing and overwhelming, especially when the words “Medicare” and “Medicaid” are used interchangeably. Both are federal healthcare programs, which only adds to the confusion. However, that’s where the similarities end. Here is a brief overview of Medicare and Medicaid.
What is Medicare?
Medicare is a federally funded health insurance program for adults over the age of 65 years, as well as some younger adults with certain disabilities.
What does it cover?
There are four parts to Medicare. Medicare Part A covers inpatient hospital and skilled nursing care, hospice care, and home health care. Medicare Part B provides outpatient and/or medical coverage, such as doctor visits. Medicare Part C offers an alternative way for older adults to receive their Medicare benefits, also referred to as a Medicare Advantage Plan. Medicare Part D is prescription drug coverage.
What does it cost?
Medicare.gov provides an overview of the costs of each part of Medicare. The costs depend on which plan you choose. Deductibles reset for each benefit period.
When do I enroll?
Most older adults enroll in Medicare when they first become eligible, which is three months prior to their. 65th birthday. Certain medical conditions may qualify an adult to enroll prior to 65 years, such as a disability, Lou Gehrig’s disease (ALS), or end-stage renal disease.
What else do I need to know about Medicare?
There are certain limits to how long Medicare will cover the costs of care. The need for skilled care must be predicated by a hospital “admission” status of at least three midnights or longer. Older adults receiving hospital care should always know their hospital status. You can be in the hospital under “observation” before you are “admitted.”
Medicare covers the full cost of medically necessary skilled care for the first 20 days at a Medicare-approved skilled nursing rehabilitation facility. After that, the patient is responsible for their co-pay from day 21 to day 100. Coverage stops after 100 days in a skilled nursing rehabilitation facility. Coverage can also stop if the patient has plateaued. The 100 days resets as soon as you’ve gone 60 days without a hospital stay.
Upon discharge from skilled care, some patients are eligible to receive home health. Medicare covers up to 30 days of skilled nursing care and/or physical, occupational therapy, and speech therapy, if medically necessary.
Medicare does not cover facility-based care if the only care needed is assistance with activities of daily living (personal hygiene, dressing, eating, using the toilet, and mobility).
What is Medicaid and who qualifies?
Medicaid is a federally funded and state-run health insurance program for low-income individuals or families, regardless of age. Qualifying for Medicaid depends on your age, physical health, financial situation, and how much property you own.
What does it cover?
Medicaid is mandated to cover medically necessary inpatient and outpatient hospital services, physician services, lab work and x-rays, and home health services. Optional benefits include prescription drugs, case management, and physical and occupational therapy.
What else do I need to know about Medicaid?
Each state has at least one Medicaid home and community-based service (HCBS) waiver program. Waiver programs pay for the care provided in the home by a home care company, adult daycare, or assisted living, if eligible.
If you have a spouse, Medicaid often considers both you and your spouse together when counting your income and assets. However, you may be able to set aside a certain amount of income and assets for your spouse to keep. If you are a homeowner, the equity from your home may count as an asset when you are being screened for Medicaid eligibility. Lastly, there are generally limits on the number of people who can receive Medicaid benefits in each state. Even if you do meet all of the criteria for a Medicaid HCBS waiver program, you may be placed on a waiting list.
At Senior Living Solutions, we understand that navigating health care is overwhelming and confusing. We are here to help. We can provide you with the tools so that you can make informed decisions regarding your health care needs or those of an aging loved one. Our mission is to relieve the stress and ease the burden of finding the best senior living options for our clients. Our clients never receive a bill for our service. If you are interested in exploring available senior living options, please contact us today by calling 501-650-3013.