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Medicare / Medicaid

Medicare is a federal health insurance program for those over 65 or with a disability. The program is funded by the Social Security Administration and consists of two separate parts. Part A assists with hospital care, and Part B is for doctor and outpatient costs. Part D, the most recent addition to Medicare, covers prescription drugs. Medicare is provided regardless of income.

Medicaid is a state-governed health insurance program providing coverage for low-income individuals. Medicaid is state-governed so its rules and coverage vary. Low-income Medicare patients are sometimes eligible for Medicaid. Medicaid can help with Medicare co-payments, deductibles, and premiums, as well as gaps in Medicare coverage. In addition to covering many of the costs Medicare doesn't, Medicaid is often available to those who do not qualify for Medicare.

Understanding Medicare

Medicare is a federal health insurance program. Funded by the Social Security Administration, it helps provide health care for those over 65 or with a disability.

How can I enroll?

If you're already getting Social Security benefits, you'll be automatically enrolled for Parts A and B when you reach 65. If you're getting Social Security disability benefits, you'll be automatically enrolled for Parts A and B after 24 months. Assuming you're eligible, you can enroll for one or both Parts by calling 1-800-772-1213, or by visiting your local Social Security Office.

How do I know if I'm eligible?

If you're over 65 and a legal 5-year resident of the United States, you're eligible for Medicare. Or, if you're a legal 5-year resident and qualified to receive Social Security disability benefits, you are eligible for Medicare.

How does Medicare work?

When you're enrolled in Medicare, the billing process is simple. When you visit a Medicare provider, they will bill Medicare directly for the coverage of the services they provide. If the service was performed under Part B, you will also receive a Medicare Summary Notice (MSN) detailing the charges the provider is billing to Medicare. This gives you a chance to review the charges resulting from your visit.

Medicare: Part A

Part A is the Medicare Plan covering hospital and hospital follow-up costs. This coverage is dependent on what Medicare defines as a "benefit period". A benefit period is a treatment period defined by the beginning of patient treatment in a facility until the patient is out of the facility for 60 consecutive days.

Coverage also varies depending on the type of facility. Hospital stays are fairly well covered, with Medicare covering most of the basics. A skilled nursing facility also has the basics covered, as long as it's a follow-up to at least a 3-day related hospital stay. Likewise, Part A will cover a psychiatric hospital stay for up to 190 days in a lifetime. It will also cover part-time or intermittent home skilled care, or even hospice care, including respite care and drug needs.

How much does Part A cost?

If either you or your spouse has paid into Social Security for at least 10 years, then there is usually no premium for Medicare Part A.

If you don't meet that qualification, however there is a monthly premium for Medicare Part A of approximately $343.00. In addition, if you will have to enroll in Plan B, which carries its own premium.

Regardless of whether you have to pay the premium, there is a deductible for care under Part A. The deductible is $876 for the first 60 days of the benefit period in a hospital, or the first 20 days of the benefit period in a skilled care facility.

After those time periods (60 days for hospital, 20 for a skilled care facility) end, there will be large co-payments for extended stays. These co-payments vary depending on the type of facility and length of stay.

Medicare: Part B

Part B is the Medicare Plan covering doctor bills and outpatient costs.

What is covered under Part B?

Part B covers very specific areas in health care. In general, it will cover 80% of the "approved charges" in these areas. An approved charge is not necessarily the amount billed by the service provider, but is actually the charge that Medicare decides is appropriate. Some of the main categories of coverage are:
  • Doctor's services
  • Some Outpatient services, skilled care & therapies, and supplies
  • Some home health care services, skilled care & therapies, and supplies
  • Diagnostic tests
  • Some ambulatory surgery center facility fees
  • Medical equipment & supplies (wheelchairs, hospital beds, oxygen, walkers, etc. as well as prosthetics, pacemakers, splints & casts, etc.)
  • Second surgical opinions
  • Outpatient mental health care
  • Clinical Laboratory Services (blood tests, urinalysis, etc.)
  • Ambulance Services when necessary
  • Emergency Care
  • Eyeglasses after cataract surgery
  • Some Chiropractic services

In addition, Medicare Part B will cover 100% of approved charges for some other healthcare services such as home health care, clinical laboratory services, and flu and pneumonia vaccines.

Medicare Part B does not cover some other major medical expenses like regular physical examinations, glasses, dentures, medical prescriptions, hearing aids, and other major medical expenses.

How much does Part B cost?

Part B of Medicare has a monthly premium of $66.60. For every year after eligibility that a person does not enroll, however, the premium could increase for that person another 10%.

In addition to the premium there is a $100 deductible once a year. The co-payments for Part B are usually 20% of approved charges, although they can vary to 50% of outpatient mental health care or even 0% of certain treatments and medical providers.

Because Medicare Part B only pays for approved charges (or what they feel the service should cost) doctors can charge you for the difference in their billing and Medicare Part B's approved charges.

Understanding Medicaid

Medicaid is a health insurance program managed by the states. Because Medicaid is governed by the state, its coverage, rules, payment requirements, and eligibility restrictions vary depending on where you live. There are certain guidelines that Medicaid programs must follow to receive matching funding from the Federal Government.

Medicaid is targeted to low-income families and individuals. It can be carried in addition to Medicare, and is often used to cover Medicare gaps in coverage, as well as costs of premiums, co-payments, and deductibles.

How does Medicaid work?

In general, healthcare providers bill Medicaid directly, and Medicaid payments are made directly to the service-providers. State Medicaid programs pay an accepted rate for the service, rather than what care providers would like to bill. Unlike Medicare Part B, healthcare providers are legally prevented from billing the patient for the difference in payment. The States have broad discretion in determining the appropriate rates for services, except in certain cases. Also, institutional service rates cannot be more than allowed by Medicare.

Who is eligible for Medicaid?

Eligibility for Medicaid varies from state to state, generally based on things like age, pregnancy, disability, blindness, income, resources, and citizenship. In general, Medicaid programs focus on low-income US citizens such as children, teenagers, pregnant women, families with children, the aged, the disabled, and the blind.

What does Medicaid Cover?

While coverage and programs vary from state to state, each program must meet certain guidelines in coverage to receive their matching federal funds. Many Medicaid programs meet most basic medical needs, as well as much of the coverage not included under Medicare.

What does Medicaid Cost?

States have discretion in determining premiums, co-payments, and deductibles. They are prohibited from charging for certain services, however, such as:
  • Emergency services
  • Family planning services
  • Pregnant women
  • Children under 18
  • Hospital or nursing home patients who are contributing the majority of their income to the facilities they reside in
  • Categorically low-income HMO enrollees

How do I apply for Medicaid?

Medicaid applications can be obtained by visiting or calling your local Department of Social Services. Applicants who are elderly or disabled can request that an application be provided by mail and can mail in their completed application. For a list of social service offices with contact information, click here.

Local senior centers often have staff that will assist in completing Medicaid applications. For a list of Virginia’s senior centers, click here.

Hospital social workers can complete UAI (Uniform Assessment Instruments) forms necessary for long-term care Medicaid for nursing home admission if the patient is unable to pay for nursing home care. If you believe you or your family member will require long-term care, it is essential to have the UAI completed while in the hospital because the social service social workers that do UAIs for the community often have long waiting lists. Hospital social workers are required to complete necessary requested UAI evaluations before you leave the hospital.

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