Navigating the landscape of healthcare in the United States can be challenging, particularly when it comes to understanding the differences between Medicare and Medicaid. These two programs are crucial for providing healthcare coverage to millions of Americans, yet they serve different populations and offer varying types of coverage. Below, our Cranston, RI Medicaid lawyer will explore what Medicare and Medicaid cover, what they don’t cover, and how each program serves its beneficiaries.
What Is Medicare?
Medicare is a federal health insurance program primarily designed for individuals aged 65 and older, though it also covers some younger people with disabilities and individuals with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare is divided into four parts, each covering different aspects of healthcare:
1. Medicare Part A (Hospital Insurance):
- Covers: Inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.
- Doesn’t Cover: Long-term care, custodial care, private-duty nursing, most dental care, vision care, hearing aids, and prescription drugs not administered in a hospital or skilled nursing facility.
2. Medicare Part B (Medical Insurance):
- Covers: Certain doctors’ services, outpatient care, medical supplies, and preventive services. It includes services like diagnostic tests, physical therapy, and durable medical equipment.
- Doesn’t Cover: Routine dental, vision, hearing services, and cosmetic surgery.
3. Medicare Part C (Medicare Advantage):
- Covers: All services covered under Parts A and B and often includes additional benefits like prescription drug coverage, dental, vision, and hearing services. These plans are offered by private companies approved by Medicare.
- Doesn’t Cover: Benefits vary by plan, so it’s essential to check specific plan details for exclusions.
4. Medicare Part D (Prescription Drug Coverage):
- Covers: Prescription drugs, both generic and brand-name.
- Doesn’t Cover: Over-the-counter medications, drugs not on the plan’s formulary, and drugs for weight loss or cosmetic purposes.
What Is Medicaid?
Medicaid is a joint federal and state program that provides health coverage to low-income individuals and families. Eligibility and benefits vary significantly by state, but there are federal guidelines that all states must follow. Medicaid primarily serves low-income adults, children, pregnant women, elderly adults, and people with disabilities.
Medicaid Coverage:
- Covers: Inpatient and outpatient hospital services, physician services, laboratory and X-ray services, home health services, and long-term care services. It also covers many preventive services, family planning, and in some states, dental and vision care for adults.
- Doesn’t Cover: Varies by state, but common exclusions include certain elective procedures, experimental treatments, and long-term non-medical custodial care. Some states may not cover dental, vision, or hearing services for adults, and prescription drug coverage can also vary.
Types Of Medicaid Coverage:
It is important to understand that there are different forms of Medicaid coverage, including community-based Medicaid and Long-Term Services and Supports (LTSS) Medicaid. Achieving a five star rating from Avvo, our top-rated lawyers can explain:
- Community based Medicaid is for individuals of all ages, based on strict eligibility criteria, including certain programs for elderly and disabled individuals who reside in the community.
- LTSS Medicaid is primarily available for older individuals who meet strict eligibility criteria and reside in residential facilities such as some assisted living facilities and nursing homes.
Key Differences Between Medicare And Medicaid
While both Medicare and Medicaid provide crucial healthcare coverage, their differences are significant:
1. Eligibility:
- Medicare: Primarily age-based (65+), with some provisions for younger individuals with specific disabilities or conditions.
- Medicaid: Income-based, with eligibility determined by each state, but generally covers low-income individuals and families, as well as seniors needing long term care.
2. Funding:
- Medicare: Federally funded and managed.
- Medicaid: Jointly funded by the federal government and individual states, with states administering their own programs within federal guidelines.
3. Coverage:
- Medicare: More uniform across the country, focusing on healthcare services and treatments for older adults and certain disabled individuals.
- Medicaid: Coverage and benefits can vary widely from state to state, often providing more comprehensive long-term care and support services for eligible individuals.
What Medicare Doesn’t Cover
Despite its extensive coverage, Medicare does have gaps:
- Long-Term Care: Medicare does not cover long-term care (custodial care) if that is the only care you need.
- Routine Dental and Vision Care: Most dental care, eye exams, dentures, and hearing aids are not covered.
- Alternative Therapies: Services such as acupuncture, naturopathy, and chiropractic care (except when medically necessary) are typically excluded.
- Cosmetic Surgery: Procedures not deemed medically necessary are not covered.
- Prescription Drugs: Medicare Part A and Part B do not cover most prescription drugs; Part D is necessary for drug coverage.
What Medicaid Doesn’t Cover
Medicaid coverage exclusions can be more variable, but common exclusions include:
- Elective Procedures: Cosmetic surgeries and other non-essential procedures.
- Experimental Treatments: New or experimental treatments and drugs that are not widely accepted as effective.
- Certain Long-Term Care Services: Non-medical long-term care services may not be covered in some states.
- Additional Services: In some states, adult dental, vision, and hearing services might be limited or not covered at all.
- Residential Care: Not all residential facilities accept Medicaid, and those that do often have a limited number of Medicaid beds. Assisted living facilities may accept Medicaid, but are not required to.
Is Medicare Or Medicaid Better?
The “better” program depends on individual circumstances. Medicare provides broader coverage for healthcare services and is more standardized nationwide, making it a reliable option for seniors and certain disabled individuals. Medicaid, on the other hand, offers more extensive coverage for long-term care and other services for those with low incomes and resources but varies significantly by state.
Do I Need Medicare And Medicaid At The Same Time?
Oftentimes an individual who needs residential care in an assisted living community or nursing home will need both Medicare and Medicaid. In these cases, Medicare will often continue to pay for medical care in the community such as doctors, hospitalizations, specialists, and medication, while Medicaid will cover the long-term care residential and medical services of the individual.
Understanding the distinctions between Medicare and Medicaid is essential for making informed healthcare decisions. Both programs play critical roles in the U.S. healthcare system, offering vital support to their respective populations. By knowing what each program covers and doesn’t cover, individuals can better plan for their healthcare needs and ensure they receive the appropriate care and support.
Collaborating with an experienced elder law attorney and elder care coordinator is essential when considering a residential facility. This partnership will help ensure that you receive optimal care in an environment tailored to your needs, while also maximizing your financial resources and protecting your assets. Contact the team at McCarthy Law, LLC for help today; we represent clients in Connecticut, Massachusetts, Rhode Island, and the surrounding communities.