Medicare vs. Medicaid: What Caregivers Need To Know Now

Medicare open enrollment is coming up. From October 15 to December 7, people can make changes to their Medicare health plans and prescription drug coverage to better meet their needs for the following year. In most cases, Fall Open Enrollment is the only time you can pick a new Medicare Advantage or Part D plan.  Medicaid enrollment for 2023 begins November 1 and runs until January 15, 2023.

Medicare and Medicaid can be confusing, even for people who routinely deal with government programs. For seniors and their caregivers, learning the differences between these federal and state programs and what each program offers could mean receiving additional funds and support for loved ones.

First, let's begin with the primary differences between Medicare and Medicaid.

What Are the Differences Between Medicare and Medicaid?

Medicare is an insurance program managed by the federal government that is primarily based on age. It does not matter what your income is when you turn 65 years old, you can qualify for Medicare insurance coverage. People on dialysis and younger disabled individuals may also receive Medicare benefits. Medicare is generally associated with medical care after retirement.

On the other hand, Medicaid programs are managed by the states within federal guidelines. Medicaid is an income-based assistance program. It covers the costs of most medical expenses for low-income individuals who do not have assets above the eligibility requirements. If a person qualifies for Medicaid benefits, they may also qualify for food assistance programs operated by the states.

How Is Eligibility Determined for Medicare and Medicaid?

A person can sign up for Medicare three months before their 65th birthday. Generally, once you turn 65, you meet Medicare benefits eligibility.

However, eligibility requirements for Medicaid programs are much more confusing.

To qualify for Medicaid, you must meet your state's income and resource requirements. If your income level exceeds the maximum income for Medicaid, you do not qualify for the program. Likewise, if your assets are worth more than the maximum resources allowed for Medicaid, you do not qualify.

Because the Medicaid eligibility requirements vary by state, you need to check with your state to determine if your loved one might qualify for Medicaid. The HHS website has resources caregivers can access free of charge to help them determine eligibility for Medicaid for their family members.

It should be noted that most seniors need help applying for Medicaid. The forms and processes used by some states can be confusing and overwhelming. You might want to consider working with your loved one to complete the forms together for them to apply for Medicaid insurance coverage.

What Are the Four Different Types of Coverage You Can Get With Medicare?

Some seniors and caregivers are confused by the different types of coverage seniors can receive with Medicare. If your family member chooses all four parts, they will pay more for Medicare coverage. However, depending on your family member's situation, Medicare health coverage may be a cost-effective way to provide for their healthcare needs.

The four parts that make up Medicare health coverage are:

Part A – Insurance for Hospital and Skilled Care

Part A covers hospice care, inpatient hospital care, care in a skilled nursing facility, and some types of in-home health care. However, be aware that the coverage for nursing facilities, including nursing homes, is generally limited.

Generally, Medicare limits coverage of skilled nursing facilities to 100 days. Your loved one would need to be out of the nursing home and not receive skilled nursing care for a least 60 days before applying to renew the benefits.

Medicaid pays for care in nursing homes on a long-term basis.

A senior generally qualifies for premium-free Part A coverage if they paid Medicare taxes. If not, they can purchase the coverage.

Part B – Medical Insurance

Part B covers many of the services provided by doctors and outpatient care. It also covers most medical supplies and preventive services.

Part B requires a monthly premium payment. The amount is automatically deducted from the person's Social Security check. It can also be deducted if the person receives income from the Railroad Retirement Board or Office of Personnel Management.

NOTE: Medicare Part A & B is known as "Original Medicare"

Together, the parts pay for most covered services. However, your loved one will pay a deductible that starts over at the beginning of each year. You can purchase a Medigap (Medicare Supplemental Insurance Policy) that helps cover co-pays, deductibles, and some services that Original Medicare does not cover, such as health care when you travel outside the United States.

Part C – Medicare Advantage Plans

Medicare Advantage Plans are Medicare-approved health coverage plans offered by private insurance companies. These health insurance programs "bundle" Medicare Parts A, B, & D. An advantage of choosing this type of coverage over Original Medicare is that Advantage Plans often cover the costs that Original Medicare does not cover, such as dental services, hearing, and vision.

Read Advantage Plans carefully before signing up. The plans can charge various out-of-pocket costs each year. Also, the plans may have different rules for the covered services.

Part D – Prescription Drug Coverage

Prescription drug coverage is offered if the senior joins a Medicare-approved plan that offers drug coverage, including Medicare Advantage Plans. The costs of Part D coverage vary. Some plans might not cover all types of drugs that a person takes. The monthly premiums for these plans vary.

What Are the Most Common Ways People Apply for Medicare?

Which type of Medicare plan works best for your family member depends on their needs. Many people choose Original Medicare with the option of adding Part D prescription coverage and/or Medigap.

Alternatively, a person may bundle all three options by choosing a Medicare Advantage Plan.

Each option has advantages and disadvantages. Additionally, some people may choose options based on what they can afford. Researching plans to determine the cost and what they cover is the best way to choose an affordable Medicare option that provides the health care options your family member needs.

What Are Common Supplemental Coverage and Waivers Your Loved One Can Access?

There are some additional coverage options that a senior can choose with Medicaid and Medicare. The need for these programs and coverage depends on the person.

For example, suppose a senior wants to remain at home living independently for as long as possible. In that case, they may want to consider a Home & Community-Based Services Waiver through Medicaid. A senior may qualify for in-home services instead of going to a nursing home or skilled nursing facility.

However, the person must demonstrate:

  • The cost of the home care will not exceed the cost of placing the person in a skilled nursing facility
  • The in-home care provides adequately for the person's welfare and health
  • The program has reasonable and adequate provider standards
  • The services for an individual and person-centered care plan

HCBS waivers allow states to tailor Medicaid services to specific needs. For seniors, it allows them to remain in the home longer.

The health and safety of a parent or loved one is what is most important to families when loved ones want to stay in their homes. Livindi can help families monitor their environment and wellbeing using sensors and other biometric devices that collect data that is analyzed and shared with the entire team of caregivers. Everyone is notified of any changes in the data which can help prevent a medical emergency. Seniors can also press the alert button to have Livindi call all family members for them should they need help quickly. 

Another program that you might want to consider is PACE (Program of All-Inclusive Care for the Elderly). The program offers elderly individuals living in the community social services and medical care. Individuals are generally duly eligible for Medicaid and Medicare. A team of healthcare providers coordinates and delivers care.

Why Do Seniors Resist Applying for Medicaid?

Unfortunately, some seniors who qualify for Medicaid refuse to apply for coverage. They believe that Medicaid is only for the most impoverished individuals in their community. They often look at Medicaid as a welfare program or "handout." They do not want to be viewed that way by their family, friends, neighbors, and community.

However, Medicaid can provide seniors with much-needed healthcare. In addition, Medicaid can work with Medicare to ensure seniors receive the care and services they need to continue living healthy, independent lives.

A family member can check the laws in their state to determine if they would be able to apply for Medicaid on behalf of their parent. In some cases, a "responsible party" might be allowed to sign the forms on behalf of the applicant. If the family member has the person's Power of Attorney, the family member might be able to sign on behalf of the applicant.

However, forging a person's name is not legal.

For many caregivers, applying for Medicaid is a time-consuming, frustrating experience. However, some physicians who practice in elder care offer to help their patients and their family members apply for Medicaid, especially if the patient needs long-term nursing home care.

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