The public health system seems to be in a constant state of flux. It is always a hot topic of political debate, and as such, the eligibility requirements and covered benefits frequently change. Below is a basic overview of the Medicare and Medicaid programs.

What Is Medicare?

Medicare is a government insurance program for the elderly and disabled. To qualify for Medicare a person must meet the following requirements:

  • Be 65 or older and eligible for Social Security or railroad retirement; or
  • Have a disability and have received Social Security or railroad retirement for at least two years; or
  • Be 65 or older and pay for Medicare coverage;
  • Be of any age with end-stage renal disease. End-stage renal disease is permanent kidney failure requiring dialysis or a kidney transplant.

Note that there are no income or financial resource criteria for eligibility for Medicare.

Medicare is administered by the Centers for Medicare and Medicaid Services (CMS). It has four parts:

  • Part A: Part A is hospital insurance. It covers hospital care, skilled nursing under certain circumstances and hospice care;
  • Part B: Part B is medical insurance for outpatient services;
  • Part C: Part C comprises Medicare Advantage Plans, which are private insurance options for covering hospital and medical costs;
  • Part D: Part D covers prescription medications.

Like all health insurance, Medicare has deductibles and copays Part A and Part B make up what is called “Original Medicare.” Generally, Part A covers hospitalization and Part B covers outpatient medical services, such as routine doctor’s visits, that are needed to diagnose or treat a medical condition. Part B also covers preventive services, which are services that can prevent illness or discover it in an early stage when the chances of successful treatment are the highest.

The two types of services covered by Part B are extensive and include many outpatient services. Part B, unlike Part A, requires payment of a monthly premium. What is referred to as “Original Medicare” comprises Part A and Part B.

Because there could be out-of-pocket costs left uncovered by Original Medicare, a market in private-sector insurance products for Medicare recipients has developed over the years. The additional options offered by these private-sector plans allows Medicare recipients to tailor their Medicare insurance coverage to their individual needs and possibly cover what Medicare does not. These are referred to as “Medicare Advantage Plans.” These are simply another way to get Medicare Part A and Part B coverage. Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are approved by Medicare but offered by private companies. They must comply with rules set by Medicare. Most Medicare Advantage Plans include Part D prescription drug coverage.

These products are marketed aggressively to senior citizens. They include such options as managed care style plans like Health Maintenance Organizations (HMO) and Paid Provider Organization (PPO) plans that may require little or no out-of-pocket payments for services. While these types of plans can limit out-of-pocket expenses, they also require a person to get their services exclusively in-network if they want the services at a reduced cost.

Some are referred to as “Medigap” insurance. They claim to pay for “gaps” in Original Medicare, i.e. services that Medicare does not cover, and usually include minimal standard coverage. A person may also be able to get enhanced coverage. These “Medigap” plans are approved by each state in which they are offered.

Medicare only pays a portion of most doctor’s visits. A patient needs to make a co-pay. A person can purchase a Medicare supplement plan to cover the co-pays, which can result in doctor’s visits that are completely covered, so there is no cost to the patient.

What Does Medicare Cover?

Specifically, Medicare Part A covers the following:

  • Inpatient care in a hospital, if a person is admitted to the hospital as an inpatient after an official doctor’s order, which says the person needs inpatient hospital care to treat their illness or injury;
  • Skilled nursing facility care;
  • In-patient care in a skilled nursing facility that is not long-term care;
  • Hospice care;
  • Home health care.

Medicare Part B covers the following

  • Medically necessary services: Services or supplies that are needed to diagnose or treat a person’s medical condition and that meet accepted standards of medical practice;
  • Preventive services: Health care to prevent illness, such as the flu, or detect it at an early stage, when treatment is most likely to work best.

A person pays nothing for most preventive services if they get the services from a health care provider who accepts assignment.

Part B also covers such items as:

  • Clinical research;
  • Ambulance service;
  • Durable medical equipment;
  • Mental health:
    • Inpatient;
    • Outpatient; and
    • Partial hospitalization;
  • Limited outpatient prescription drugs.

Part D of Medicare is an insurance plan for prescription medication. There are two ways to get Medicare drug coverage:

  • A person can add a Medicare Prescription Drug Plan, Part D, to their Medicare-approved insurance policy; or
  • A person can get a Medicare Advantage Plan, Part C, such as an HMO or PPO that offers Medicare prescription drug coverage.

Medicare does not cover everything, of course. For example, Medicare does not cover the following:

  • Prescription drugs: As noted above, a person must obtain prescription drug coverage separately from Medicare Parts A and B;
  • Eye and physical examinations: Again, if a person wants vision care coverage, they would have to purchase a separate policy for this purpose;
  • Dental services: Again, a person who wants dental care coverage would need to purchase a separate dental care policy;
  • Immunizations, with certain exceptions;
  • Cosmetic Surgery.

What Is Medicaid?

Medicaid is a health insurance program funded by both the federal and state governments, but managed by the states. It provides free health insurance to about 75 million low-income and disabled people, who made up 23% of the American population in 2017. In 2019, Medicaid paid for half of all U.S. births, as that is the percentage of infants in the country who were born to Medicaid recipients in that year.

At the present time each state has the authority to determine who is eligible for its Medicaid program. The federal government does not require states to participate in the program, although every state does offer some version of Medicaid. Generally, Medicaid recipients must be U.S. citizens or qualified non-citizens, and they include low-income adults, their children, and people with certain disabilities.

LIke Medicare, Medicaid is administered by the U.S. Centers for Medicare & Medicaid Services, headquartered in Baltimore, Maryland. To be eligible for Medicaid, a person must have a limited income and limited financial resources. This criterion plays no role in determining Medicare coverage. Medicaid also covers a wider range of health care services than does Medicare.

The Patient Protection and Affordable Care Act (PPACA, and commonly referred to as the “ACA”) significantly expanded eligibility for Medicaid. It also increased federal funding of Medicaid. Under the law, all U.S. citizens and qualified non-citizens who have incomes up to 138% of the federal poverty line, including adults without dependent children, qualify for Medicaid in any state that participates in the program.

What Does Medicaid Cover?

Each state establishes and administers its own Medicaid programs. So, each state determines the services that its Medicaid program covers within broad federal guidelines. States are required by federal law to provide certain mandatory benefits, but the federal government allows states to choose whether to cover other optional benefits.

Among the mandatory benefits are in-patient and out-patient hospital services, physician services, laboratory and x-ray services, and home health services. Prescription drugs are among the optional benefits.

There are two general kinds of coverage under Medicaid. One is “Community Medicaid.” It helps people who have little or no medical insurance. The other is Medicaid nursing home coverage. For those who are eligible, this helps pay for the cost of living in a nursing home. The insured person also has to pay most of their income toward the cost of nursing home care, and they usually keep only $66.00 a month to cover other expenses.

Some states operate a program known as the Health Insurance Premium Payment Program (HIPP), which allows a recipient of Medicaid to have private health insurance coverage paid for by Medicaid. Few states have premium assistance programs.

Dental services are Included in the Social Security program under Medicaid. Registration for dental services is optional for people who are 21 and older but required for people eligible for Medicaid and under 21. The required minimum services offered by a Medicaid dental care program include pain relief, restoration of teeth and maintenance of dental health.

Do I Need an Attorney?

Medicare and Medicaid are important programs that help millions of Americans access affordable healthcare, but the laws that govern them are complex. To confuse matters more, Medicaid laws are different in every state.

Having a healthcare lawyer familiar with the relevant federal and state laws can help you get the coverage that can make your life easier. A lawyer will know which laws apply in your state and how to deal with government agencies.