Medicare Versus Medicaid – What’s The Difference?
Medicare versus Medicaid are both government-funded health insurance programs, but there are some key differences between the two. Medicare is available to seniors, while Medicaid is available to low-income adults and children. Medicaid also covers more services than Medicare does.
Let’s take a closer look at these two programs in order to make better decision at building the right health plans for you or your loved ones.
Medicare is a national program administered by the Federal government, comprising:
● Part A – Hospital Insurance: Inpatient hospital, skilled nursing facility, hospice, and some home health services are available.
● Part B – Medical Insurance: Outpatient care, durable medical equipment, home health care, and a variety of preventive services are all available.
● Part C – Medicare Advantage plans (MA): Private insurance companies that are Medicare-approved and provide all Part A and Part B services, as well as prescription drug coverage and other supplemental benefits.
● Part D – Prescription Drug Benefit: Outpatient prescription drug coverage provided by Medicare-approved private insurance companies
Those who are eligible for Medicare: People 65 or older; People with certain disabilities; People diagnosed with end-stage renal disease (ESRD)
Medicare is the nation’s largest payer of inpatient hospital services for the elderly and people with ESRD.
Medicaid is a network of Statewide health insurance programs administered by the U.S governments following broad national guidelines established by Federal statutes, regulations, and policies. Those who are eligible for Medicaid health insurance: Low-income adults; Pregnant women; Children. Eligibility varies from State to State. Medicaid is the nation’s largest payer of mental health services, long-term care services, and births. Medicaid pays for 40 percent of all births.
Medicare Versus Medicaid Beneficiaries
|Health insurance for:|
● People 65 and older
● People under the age of 65 with certain disabilities are eligible for Social Security disability or Railroad Retirement Board benefits for a period of 24 months (the 24-month waiting period is waived for people with amyotrophic lateral sclerosis [ALS], also known as Lou Gehrig’s disease).
● People of any age with ESRD
|Individuals must meet eligibility requirements as well as State regulations.|
The federal government requires states to cover certain eligibility groups while allowing them the flexibility to cover others.
All states provide eligibility for the following populations:
● Children and adolescents
● Parents or caretaker relative ofminor children
● Certain people with disabilities or blindness
● Pregnant women
● Youth “aging out” of foster careFor many eligibility groups, individuals must meet certain resource limits.
In addition, individuals must meet State and Federal requirements for: Immigration status, Residency, U.S. citizenship
Dual Eligible Beneficiaries
Beneficiaries who are both Medicare and Medicaid eligible are referred to as “dual eligible beneficiaries.” Beneficiaries enrolled in Medicare Part A, Part B, or both and receiving full Medicaid benefits or assistance with Medicare premiums or cost sharing through one of these Medicare Savings Program (MSP) eligibility groups are included in this definition.
- Qualified Medicare Beneficiary (QMB) Program: Assists with the payment of Part A, Part B, or both programs’ premiums, deductibles, coinsurance, and copayments.
- SLMB (Specified Low-Income Medicare Beneficiary) Program: Assists with the payment of Part B premiums.
- Qualifying Individual (QI) Program: Assists in the payment of Part B premiums.
- QDWI Program: Pays the Part A premium for certain disabled and working beneficiaries who have disabilities.
|Beneficiaries may choose coverage as follows:|
– Part A and Part B services are provided through the Original Medicare Program, with optional – Part D coverage provided through a separate Prescription Drug Plan.
– Part A and Part B services are available through an MA Plan if they live in its service area, and some MA Plans include Part D coverage.
Note: Some beneficiaries obtain a Medicare supplement plan (also known as Medigap) to supplement their Original Medicare coverage.
Part A helps cover:
● Inpatient hospital care
● Skilled nursing facility care
● Hospice care
● Home health care
Part B helps cover:
● Services from doctors and other health care providers
● Outpatient care
● Home health care
● Durable medical equipment
● Many preventive services
Part C includes all benefits and services covered by Parts A and B, as well as optional benefits and services.
Part D helps cover the cost of prescription drugs.
|Some Medicaid programs directly pay for care. Others provide Medicaid coverage through private insurance companies. Certain services must be covered by states’ Medicaid programs, including:|
● Doctor visits
● Inpatient and outpatient hospital services
● Mental health services
● Needed medications
● Prenatal care and maternity care
● Preventive care, such as immunizations, mammograms, and colonoscopies
States may choose to cover added services. Some of these include:
● Dental services
● Home and community-based services
● Physical therapy
● Prosthetic devices
● Vision and eyeglasses
The Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit provides vision, dental, hearing, and other services to children and adolescents.
Other Common Types of Coverage
You may encounter patients with health care coverage other than Medicare or Medicaid. These programs include: Private insurance program coverage (such as group health plan or retiree coverage), TRICARE, COBRA, Workers’ Compensation, Liability insurance coverage.
|On the Medicare.gov website, you can find more information about the Medicare program.|
Medicare enrollment applications are processed by the Social Security Administration.
You can learn about any national and local determinations regarding coverage for specific medical services by searching the Medicare Coverage Database.
Check to see if your patient is eligible for Extra Assistance With Medicare Prescription Drug Plan Costs.
|On the Medicaid.gov website, you can find more information about the Medicaid program.|
If you have any questions, please contact your state Medicaid office.
Using the Medicaid & CHIP Coverage tool, you can determine whether your patient qualifies for Medicaid in your state based solely on income.
Share simple infographics on common Medicaid questions, or use the Medicaid Program Integrity Education webpage to find key messages and tips.
|MLN provider-supplier enrollment educational products provide health care professionals with information about enrolling in Medicare.||More information about your state’s Medicaid program can be found on the State Overviews page.|
Billing and Claims Submission
|The Medicare Billing: 837I and Form CMS-1450 and Medicare Billing: 837P and Form CMS-1500 publications contain information about submitting Medicare claims.||While each state Medicaid program is different, general rules require you to:|
– bill only for covered services
– ensure that beneficiaries are eligible for the services that are provided
– ensure that medical records are accurate, legible, signed, and dated
– return any overpayments within 60 days.
More information about your state’s Medicaid program can be found on the State Overviews page.
|On the MLN Publications page, you can find payment information for your provider type. In the Filter field, type “Medicare Payment Policy.”||More information about your state’s Medicaid program can be found on the State Overviews page.|
|The Medicare Parts A & B Appeals Process booklet and the two web-based trainings “Part C Organization Determinations, Appeals, & Grievances” and “Part D Coverage Determinations, Appeals, & Grievances” on the MLN LMS contain information about Medicare appeals.||More information about your state’s Medicaid program can be found on the State Overviews page.|
|The MLN Provider Compliance webpage contains information about compliance as well as fraud, waste, and abuse.||The Medicaid Program Integrity Education webpage contains information about program integrity in the Medicaid Program. More information about your state’s Medicaid program can be found on the State Overviews page.|
|For information on rulings, transmittals, manuals, and other guidance, go to the CMS Regulations & Guidance webpage.|
MLN Matters® Articles are national articles that keep health care professionals up to date on the latest CMS program changes.
On the MLN News & Updates website, you can sign up for MLN electronic mailing lists and access MLN Connects® newsletters.
|CMS provides Medicaid operational guidance to state Medicaid directors, state health officials, and other stakeholders. This information is provided in the form of letters, informational bulletins, and frequently asked questions.|
CMS also issues Federal regulations that codify previously outlined statutory provisions and policies in subregulatory guidance. Search the Medicaid Federal Policy Guidance webpage for these documents.
In this article, we have taken a closer look at the differences between Medicare and Medicaid. Of course, there is a lot to discuss about these two programs, but it is our hope that this overview has helped you narrow down your options and get a sense of which will be best for you.