Medicare Versus Medicaid

Medicare and Medicaid are two government-sponsored health insurance programs. Both programs have been in effect since 1965, and they are both relatively popular with the American public.

The two names are somewhat similar and are often confusing for most consumers. However, there are numerous differences between the two programs. These differences and the advantages of each should be put into consideration before deciding which one to choose for your situation.

Medicare

Medicare is a federal program that is available to people older than 65 and certain others who are disabled. The program’s purpose is to cover hospital or medical expenses when a person cannot pay for them out of pocket. It’s worth noting that eligibility for Medicare has nothing to do with income level.

While Medicare is a federally-administered program, there are also some insurance companies that also sell Medicare plans. Medicare pays for most medical costs, including end-of-life care, hospice, or institutional care. It generally has four parts, each of them covering a different thing. These four parts work together in some cases.

Part A: Hospitalization Coverage

It covers inpatient hospital stays, care in a skilled nursing facility after an illness or injury, home health care, and hospice care. It is funded through a payroll tax collected by the federal government.

Part B: Medically Necessary Services

It is also funded through a payroll tax collected by the federal government and covers all services that are deemed medically necessary. The following are some examples of medically necessary services:

• Outpatient care
• Visits to the doctor
• Inpatient care
• Outpatient prescription drugs
• Blood transfusions
• Medical equipment and supplies
• X-rays, laboratory tests, and other scheduled procedures

With this coverage, you won’t need to pay anything for most diagnostic, treatment, and preventive services. However, you must get these services from a healthcare provider who accepts assignments. You should also note that this coverage only applies to services that meet accepted standards of medical practice.

Part C: Medicare Advantage Program

This coverage works in conjunction with Parts A and B, providing additional coverage to seniors. Part C insurance is sold by private insurers, and it is funded by a combination of premiums and federal subsidies.

The structure of this program varies significantly across states. This is because regulations regarding coverage, eligibility, cost-sharing, and quality of care standards are set at the state level. This program offers extra coverage, such as hearing, vision, and dental. It also offers coverage for health and wellness programs. In most cases, it also includes prescription drug coverage, which is part D.

Part D: Prescription Drug Coverage

Part D provides prescription drug coverage to Medicare-eligible people and those enrolled in other health insurance programs. Under Part D, you will pay a portion of the costs for the drugs you buy with your Medicare benefits.

The following are the three main factors that determine Medicare coverage.

1. Federal and state laws governing health insurance.

2. The structure of each state’s Medicare program.

3. Private insurers contracted by the government to manage the benefits of Medicare recipients.

Medicaid

Medicaid is a joint federal and state program that is available to people with low incomes. However, it differs from Medicare in several important ways. Unlike Medicare, Medicaid offers more comprehensive coverage. As a result, people who qualify for Medicaid do not usually have to pay anything out of their own pocket.

Medicaid was originally designed to help the poor and disabled get decent medical care. However, by the 1980s, it had lost its focus on certain groups. The eligibility requirements have also changed over time. Medicaid was expanded to cover more people in the late 1990s and now covers low-income families, including children and pregnant women. It is often seen as a last resort for people without access to other resources.

Medicaid Eligibility and Costs

States have more flexibility with Medicaid than with Medicare because it is administered at a state level. Each state has its own specific requirements for eligibility. However, eligibility is generally based on income and certain medical conditions.

While each state manages its own Medicaid program and sets its own rules, there are several general criteria that determine Medicaid eligibility.

Income Level

Generally, all US citizens and legal residents with incomes that are 138% below the poverty line qualify for Medicaid coverage. In most cases, people who qualify for Medicaid lose their eligibility if they accumulate a lot of wealth or if they fail to provide the documentation required to verify their income.

Geography

Each state has the authority to decide where its Medicaid recipients will receive care. In most cases, this means that recipients must get their care within their state of residence. There are exceptions to this rule, such as emergency care. You must provide the documentation required by the state to verify your residence to maintain eligibility.

Medicaid Benefits

Medicaid benefits vary from state to state. However, the federal government mandates that all states cover certain essential benefits. These include the following.

1. Medically Necessary Services

These include physicians, inpatient hospitals, outpatient hospitals, nursing facilities, and home health services.

2. Family Planning Services

There are no coverage restrictions on family planning-related services.

3. Screening and Diagnostic Tests

All states must cover diagnostic services, including X-ray services, laboratory tests, and EPSDT.

4. Emergency Services

All states must provide coverage for emergency services, such as nurse midwife services and transportation to medical care.

In addition to these essential benefits, all states are allowed to include additional services in their Medicaid plans. These include prescription drug coverage, eyeglasses, optometrist services, and physical therapy.

Most states use federal guidelines to determine whether a service will be covered or not. However, there are some exceptions to this rule. Some states have added additional services that are not listed in the federal guidelines, such as dental care for people with low incomes and nutritional counseling for pregnant women.