Are you feeling intimidated by the complex process of choosing a healthcare insurance plan, understanding medical jargon, and navigating high costs for care? You are not alone. Making sense of healthcare insurance options can sometimes feel like an overwhelming journey, and many people need clarification about what services are covered and how to access the care they need. This can lead to delayed treatment due to anxiety regarding decision-making, which can impact one’s health outcomes in the long run. Thankfully, government programs like Medicaid and Medicare create a pathway to support by providing coverage to low-income individuals, families, and seniors, and helping reduce some financial burdens. If you ever wished that understanding these programs could be easier, this blog is for you!
Understanding Medicare vs. Medicaid
First, let’s talk about each of the programs and how they compare. Medicare and Medicaid are both government programs that provide health coverage to individuals in need. But, how do they differ? Let’s go through an overview of each.
What is Medicare?
Medicare is a program designed primarily for seniors aged 65 and older to ensure access to affordable healthcare, reduce financial burdens on services, and improve health outcomes. In addition to seniors, Medicare also covers certain populations of younger people with disabilities or particular medical conditions.
To be eligible for Medicare, you must fall into at least one of the following categories [1]:
- You are 65 years old or older.
- You are under 65 years old and have received Social Security Disability Insurance for at least 24 months.
- You have specific medical conditions, such as End-Stage Renal Disease or Amyotrophic Lateral Sclerosis.
The Four Parts of Medicare [2]:
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- Part A (Hospital Insurance) covers inpatient hospital stays, care from nursing facilities, hospice care, and specific home health services. Part A typically does not require a premium if you or your spouse paid Medicare taxes while working.
- Part B (Medical Insurance) covers outpatient care, doctor appointments, preventative screenings/services, and specific home health services. Individuals usually pay a monthly premium for this part based on their annual income.
- Part C (Medicare Advantage) includes coverage from Part A and Part B, plus additional benefits, such as vision, dental, and wellness services. Plan C may have different costs and coverage options since it is a private insurance plan.
- Part D (Prescription Drug Coverage) covers a portion of prescription drugs through private insurance plans. Individuals pay a monthly premium for this part. Coverage may vary depending on the plan.
What is Medicaid?
Medicaid is a federal and state program that provides health coverage to low-income individuals and families to ensure that vulnerable populations can access the care they need and deserve. In addition to low-income individuals and families, Medicaid also helps provide coverage to children, pregnant individuals, the elderly, and those with disabilities.
Similar to Medicare, Medicaid has certain eligibility requirements. To be eligible for Medicaid, you must fall into at least one of the following categories [3]:
- You meet the income threshold of your state.
- You are a resident of the state in which you are applying.
- You are part of a “vulnerable population,” including children, pregnant individuals, parents/caregivers, elderly individuals, or disabled individuals.
- You are a U.S. citizen or a qualified non-citizen.
Medicaid provides coverage for a wide range of services and usually covers services not included in Medicare. Some of the services that Medicaid helps cover are [4]:
- Inpatient and Outpatient Hospital Services: Medicaid covers necessary hospital stays and outpatient services.
- Physician Services: Medicaid helps cover regular doctor visits and specialist care appointments.
- Preventative Services: Medicaid helps cover vaccinations, screenings, and wellness checks.
- Long-Term Care: Medicaid helps cover nursing home care and community-based services for individuals who require long-term care.
- Mental Health Services: Medicaid helps cover mental health treatment, like therapy.
- Prescription Drug Coverage: Medicaid helps cover prescription medications.
- Dental and Vision Services: In certain states, Medicaid helps cover dental and vision services.
Can You Have Medicare and Medicaid?
After reading about what Medicare and Medicaid cover, you may wonder if you can have both. Dual eligibility and enrollment allow you to access the best of both worlds and benefits from both programs, creating a more comprehensive healthcare safety net [5].
This is called “concurrent enrollment,” and having it can give you many advantages, such as:
- Comprehensive Coverage
- Lower Out-of-Pocket Costs
- Access to Additional Services
How, exactly, do the two programs work together? Medicare and Medicaid work together as your primary and secondary healthcare coverage. Medicare is typically the primary payer for services, and pays first, while Medicaid acts as the secondary payer and makes up for any of the additional costs not covered by Medicare. Copayments, coinsurance, and deductibles are not always covered by Medicare, which is why it’s good to have Medicaid as a backup [5].
Who is Eligible for Both Medicare and Medicaid?
You must qualify for both Medicare and Medicaid to qualify for dual enrollment. Therefore, you should fit into the following categories [6]:
- You are 65 years old or older, or under 65 with a qualifying disability (and receiving Social Security Disability Insurance for at least 24 months)
- You meet your state’s income limits for Medicaid
- You have limited assets, which are determined based on state
- You are a resident of the state in which you are applying
- You are a a U.S. citizen or a qualified legal resident
- You are enrolled in Medicare Parts A and/or B
How to Apply for Medicare and Medicaid
Now that you know the eligibility requirements for Medicare and Medicaid and their benefits, let’s learn how to apply to these programs.
To apply to Medicare [7], first, you must choose which enrollment period you plan to apply during. The initial enrollment period starts three months before your 65th birthday and ends three months after. The special enrollment period may be available through your or your spouse’s place of employment’s health coverage.
Next, gather all the required information and documents you need to apply. This includes your social security number, birth certificate (or proof of age), and employment details (if applicable). After gathering these, choose how you will apply. You can apply online through the Social Security Administration website, over the phone, or in person at your local Social Security office. After completing your application, you will receive a confirmation of your enrollment.
To apply for Medicaid [8], you will also need to gather required documentation, like proof of income (often shown through pay stubs or tax returns), bank statements and asset documentation, your social security numbers, and a valid form of identification (like a driver’s license). Then, visit your state’s Medicaid program website and follow the application instructions. You may be able to apply online, by phone, or in person, depending on what your state offers. About two weeks after applying, you’ll receive your eligibility.
As a general tip, make sure to organize your documents early and create a checklist to keep track of all these steps. If you are unsure about the application process or feel confused about any steps or questions, reach out to an advocacy group, social worker, or trusted friend/family member for assistance.
How Senior Primary Care Providers Can Assist with Medicare and Medicaid
Primary care providers play an important role in assisting seniors with Medicare and Medicaid, by educating them about their health needs, which can help patients make an informed decision on which healthcare options work best for them. They may be able to provide resources for enrollment, which can create a smoother process. Primary care providers can also help coordinate care with specialists so that all of their patient’s providers are aware of the patient’s coverage and the services that are available to them. This coordinated team can help monitor the senior’s health conditions and ensure they receive prompt care and preventative screenings, increasing their quality of life and overall health.
Medicare and Medicaid Primary Care at Greater Good Health
Greater Good Health provides dedicated support with Medicare enrollment and coverage. Find a location near you and contact Greater Good Health for an appointment to learn more about healthcare coverage.