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Know The Differences Between Medicare and Medicaid

Question: I get Medicare and Medicaid confused. What is the difference?

Answer: Original Medicare is a Health Insurance provided by the Federal Government under the direction of Centers for Medicare & Medicaid Services (CMS). Original Medicare is Part A-Hospitalization and Part B-Medical coverage. Medicare is Health Insurance Coverage for those that are eligible to receive it. Medicare is a benefit that most people are eligible for at age 65. Some receive Medicare earlier in life due to a disability.

Many of my articles have covered Medicare and its parts in many ways. So today I will focus on Medicaid quite a bit more.

Medicaid is also under the direction of Centers for Medicare and Medicaid Services (CMS). The difference is Medicaid is a combination of federal, state and local funding providing Medical Benefits and other supportive services for those that meet the eligibility criteria (Income and Assets).

I will break this down into a very simple explanation. Medicaid is a very large umbrella of programs. Each program has slightly different eligibility criteria and standards and how it works with providers in our community. Also, please remember that I mostly work with the elderly, so I do focus on how and what it does for that age group.

I will begin with what I call Community Medicaid and then move onto Long Term Medicaid. Both of these benefits require an application be submitted to Department of Health & Human Services (DHHS), in your county. This application requires a significant amount of information and then requires supporting documentation for that information.

The application(s) for the following benefits can be obtained by going to the County DHHS office closest to you, Jamestown or Dunkirk for Chautauqua County. For Cattaraugus County you would get that information from Olean or Little Valley. They can also be found on the mybenefits.ny.gov website. You can also call your local DHHS office and request one be mailed to you.

Community Medicaid allows for an individual to live in their home, apartment or assisted living facility and still receive coverage for their medical costs. Community Medicaid has an income cap of $879 for one person or $1,287 for a couple. As the household size increases the monthly income increases. I work with primarily seniors so my households generally stop at two people. This Medicaid benefit does have a resource test. That means you have to be below $15,450 for one person or $22,800 for two people with regard to assets. This is money in the bank, investments, bonds, life insurance, etc. If you live in your home, your home is not counted as an asset. If you live elsewhere that property is included in this asset amount.

Community Medicaid will pay for health insurance premiums (Medicare and others). It will pay for medical equipment, homecare, medical transportation services, hospital stays, dental care, vision needs, medications and many other things. Community Medicaid is a much larger benefit. If you have other insurance (like Medicare) Medicaid would always be secondary, except for those services not covered by Medicare. An example is dental services; Medicare does not cover dental, so Medicaid would be the primary payer for dental care. Medicaid is always considered the payer of last resort.

Another Medicaid level of coverage is Long Term Medicaid. This I will cover briefly, as it is a complicated program that provides services in many different settings. In some situations this Medicaid requires a one year look back at financial transactions and some situations it requires a five year look back at financial transactions.

Long Term Medicaid is the benefit that requires a much larger application. This is a two part application which you would get from DHHS. This Medicaid also requires much more supporting information. Long Term Medicaid for some waiver programs (example- Traumatic Brain Injury Program (TBI-Waiver) requires the longer application, but only a one year look back. Long Term Medicaid for Skilled Nursing Care uses that longer application and has a five year look back period. That means in order to be determined eligible for this benefit you must document and prove five years’ worth of financial records to DHHS. I often stress keeping your financial records for at least five years and this why.

Long Term Medicaid is often called Nursing Home Medicaid. I would like to clarify that you don’t have to live in a Nursing Home to get this benefit. You could remain in your own home and receive care there and have Medicaid help pay for that care.

This Long Term Medicaid includes the benefits previously mentioned in Community Medicaid and also the cost of care for the individual in the Nursing Home or for the cost of care while living in their home.

The asset test for this is very different. This asset test includes that five year review of your finances. It allows for an individual to keep $15,450 in assets/resources. The monthly income cap for one person is $1,192, but I have had clients who make more than that and still be approved. (That is because a Nursing Home clearly costs more than that.)

For couples this Long Term Medicaid has another level of benefit that is called Spousal Impoverishment Medicaid. I will briefly say that this income cap is $3,210 per month. This amount is divided between $50 for the Institutional Spouse (living in the nursing home or receiving services) and $3,160.50 for the Community Spouse (still living independently). The resource test is also very different; the Institutional Spouse can keep $15,450 in their name and the Community Spouse can keep the house they live in, the car they drive and between $74,820 and up to $126,420 in resources/assets. This benefit allows for the community spouse to keep a higher amount of income and assets, so they can maintain successfully in the community.

I will say again, I have simplified these benefits to explain briefly in this article. I have done so to give you information to keep on hand and in mind as you look at your own life. If you need more in-depth information I can address that in future articles or you can call for more information. There are always extenuating circumstances, so some of this information could apply slightly differently to you due to your particular situation.

Medicare and Medicaid are words that sound similar, but provide very different benefits. I hope this helps to clarify some of your confusion.

To contact Janell Sluga, GCMC with questions or concerns, please call 720-9797 or e-mail her at janells@lutheran-jamestown.org.

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