Medicare Vs. Medicaid
Medicaid is a means-tested program, which means that eligibility is based on a person’s income and assets. It is administered by the state, in accordance with the federal government. Medicaid provides medical coverage to certain groups of individuals with low income. Two of these groups are people with disabilities and elderly individuals in need of long-term care. For people with developmental disabilities, Medicaid has another critically important function—it provides access to Medicaid support services such as day programs, job coaching, support brokers, residential housing, and many other important services. Without Medicaid, an individual cannot access many of the services offered through the Office of People with Developmental Disabilities (OPWDD).
Medicare is a federal health insurance program for people in the U.S. who are 65 and older as well as some younger people with disabilities. You must be a U.S. citizen or legal resident for at least 5 consecutive years and one of the following:
- Age 65 or older
- Under age 65 with a qualifying disability
- Any person diagnosed with end-stage renal disease or ALS
Original Medicare has 2 parts:
- Part A – Hospital Insurance
- Part B – Medical Insurance
Medicare Part C is also known as Medicare Advantage and is an alternate way to get your Medicare benefits. Medicare Advantage plans are sold by private insurance companies and cover services normally covered by Medicare Part A, Part B and sometimes Part D (prescription drug coverage).
Part D is Medicare Prescription Drug Coverage and must be purchased separately unless it is included in a Medicare Advantage plan.
Medicare Supplement (Medigap) plans are sold by private insurance companies and designed to cover the gaps in Medicare parts A and B. Medigap policies supplement Original Medicare and serve to limit your out-of-pocket expenses. They are regulated by state and federal agencies. You must purchase a separate Part D stand-alone prescription drug plan in order to cover your prescriptions.
Many individuals with developmental disabilities receive Social Security Income (SSI) which includes Medicaid benefits. In certain situations, the person may also qualify for Medicare benefits. If this is the case, the individual is considered to be a “dual eligible.”
In order to avoid the deductibles, copays and coinsurances associated with Original Medicare, a dual eligible must use a doctor or facility that accepts Medicaid. As a result, some people are switching to a Medicare Advantage plan with a low or $0 monthly premium, or adding a Medigap policy to cover the gaps in Original Medicare when the doctor doesn’t accept Medicaid.
Medicare and Medicaid can be confusing. If you have any questions about your coverage, call my office at (631) 286-1061.