Medicare vs. Medicaid for Seniors: An In-Depth Comparison
Seniors Blue Book Utah
Mar 15, 2023
Utah - Utah
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Medicare vs. Medicaid for Seniors: An In-Depth Comparison
Navigating the world of healthcare for seniors can be a complex and often confusing task, especially when it comes to understanding the differences between Medicare and Medicaid. As a senior or caregiver, knowing which program offers what types of coverage is essential for ensuring the elderly receive the best possible care. In this blog, we will explore the key differences between Medicare and Medicaid, their benefits, and which one might be the right choice for you or the seniors in your life.
Understanding Medicare: The Basics
Medicare is a federally-funded health insurance program primarily designed for individuals aged 65 and older, along with younger people with certain disabilities. The coverage of this program is split into four parts: Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage), and Part D (Prescription Drug Coverage).
Part A covers inpatient hospital care, skilled nursing facilities, hospice care, and some home health services, while Part B focuses on outpatient care, including preventive services, laboratory tests, and medical supplies. Part C, or Medicare Advantage, offers an alternative to traditional Medicare, combining Parts A and B and often Part D as well, and is provided by private insurance companies. Medicare Part D offers prescription drug coverage, helping seniors manage the costs of necessary medications.
Understanding Medicaid: The Basics
Medicaid, on the other hand, is both federally and state-funded and serves low-income individuals and families, including seniors. Each state has its guidelines for Medicaid eligibility, making it essential to consult your local Medicaid office for accurate and up-to-date information.
Medicaid offers a wide range of services, including inpatient and outpatient hospital services, laboratory and X-ray services, home health services, and nursing facility services. Crucially, Medicaid also covers long-term care services that Medicare does not typically provide, such as assistance with daily living activities and nursing home care.
The Key Differences Between Medicare and Medicaid
Now that we've covered the basics, let's dive deeper into the differences between Medicare and Medicaid for the elderly. The most significant difference is eligibility: while Medicare is virtually guaranteed for those aged 65 and over, regardless of income, Medicaid is specifically for individuals with limited income and assets.
Another fundamental difference is the scope of coverage: though Medicare covers a wide range of medical services for seniors, it falls short in long-term care coverage, something that Medicaid excels in. This makes Medicaid the better choice for seniors who may require extensive nursing home care or long-term assistance with daily living activities.
Dual Eligibility: Can Seniors Have Both Medicare and Medicaid?
In some cases, seniors can qualify for both Medicare and Medicaid coverage, referred to as "dual eligibility." This occurs when an individual meets the requirements for Medicare (typically being aged 65 or over) and has limited income and resources, qualifying them for Medicaid.
For those who are dually eligible, Medicare primarily covers medical services, while Medicaid picks up any remaining costs, including long-term care services. Dual eligibility can offer substantial financial relief for seniors, as Medicaid may cover out-of-pocket expenses such as premiums, deductibles, and copayments that would usually fall upon the individual.
Choosing the Right Program: Factors to Consider
When determining whether Medicare, Medicaid, or both are the correct choices for you or the senior in your care, there are several factors to consider. First, take a close look at eligibility requirements, paying close attention to income limits for Medicaid in your state. Remember that eligibility for Medicare is virtually guaranteed for those 65 and older, while Medicaid eligibility depends primarily on income and resources.
Next, consider the type of care needed. If the senior in question requires long-term care services or comprehensive nursing home care not typically covered by Medicare, then Medicaid may be the better choice. Considering financial factors, such as out-of-pocket expenses, is essential in making an informed decision.
Taking Action
Deciding between Medicare and Medicaid for the elderly can be a daunting task, but understanding the basics of each program, their differences, and eligibility criteria can help guide you toward the right choice for your situation. Remember to weigh the type of care needed and financial factors when determining the best course of action, and consult with your local Medicaid office for state-specific information. Ultimately, making the right choice between Medicare and Medicaid can ensure that you or your loved ones receive the healthcare you deserve in your golden years.
There are two important dates to keep in mind when considering Medicare and Medicaid: the initial enrollment period for Medicare begins three months before an individual’s 65th birthday and ends three months after their birthday. Additionally, there is an annual open enrollment period beginning on October 15th and ending December 7th. During this time, individuals can make changes to their current coverage or switch plans entirely. For Medicaid, eligibility can be determined at any time and applications can be submitted throughout the year. The application process may take several weeks to complete, so it is important to start planning ahead of time.
For more information, or referrals to Medicaid Planners or Medicare Advantage insurers, contact us at info@seniorexpo.org or call 888-813-4824
Visit the Senior Expo this October to talk to experts in person and learn about your Medicare options in time for open enrollment. Register for your free admission at SeniorExpo.org
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Healthcare and Hidden Limitations
Health insurance jargon can be the hardest to understand for consumers. Thats why you have a broker who goes to work for you and explains your policy options with clarity. However, not all brokers work ethically. You may not have an insurance broker who values you and may not elaborate on your policy limitations. The omission of these limits is illegal and should result in the termination of that broker. In contrast, the insured typically doesnt take legal action, and the broker makes his or her desired commission.This is not to say that all health insurance brokers operate in this zone of immorality. Just as with any profession, there are good and rotten eggs. Your moral compass and ability to judge a persons intention is a significant factor people can typically smell a sleazy salesperson. Below, are the most common limitations obscurely mentioned in health insurance policies. This information should adequately equip you for when you are asking questions of your broker.Heres a screenshot from the summary of the benefits of an insurance carriers product:*Note these limitations do not exist in all policies. Ask your broker.The list of benefits above is towards the end of the policy summary. Most people are interested in seven factors when it comes to their health insurance:Deductible/coinsurance/max out of pocket, doctor visits/specialists/urgent care, the network, prescription coverage, preventative/wellness coverage, emergency room fees, and ambulatory services. If your insurance broker goes over those seven things, this is how the policy would look and sound:Choice of $500-$10,000 deductible/max out of pocket (1 million in coverage)Choice of 70/30, 80/20, or 100/0 coinsuranceUnlimited $25 copay to doctor, specialist, and urgent carePHCS Network (PPO)$50 copay for annual wellness/preventative checkupER subject to deductible and coinsuranceAmbulatory services (above) $500 per transportMost people would agree that those seven things sound fantastic for health coverage. You have all your daily doctor needs taken care of and one million dollars in coverage, right? Wrong, let me show you a scary breakdown if you had an appendectomy while being covered by this policy.On average, the Fair Price for an Appendectomy lies somewhere between $7,000 and $25,000 (may vary due to zip code). If there are complications, it could be upwards of $35,000 or more. Heres a breakdown of the services and their estimated costs. You can always check on any surgery, and its price by visiting Healthcare Bluebook.Hospital Services for a 2-day admission, itll cost roughly $9,700.Physician Services the fee for procedure and routine postoperative care costs around $1,400.Anesthesia the price for an average surgery time of 1 hour and 15 minutes costs about $750.This cost adds up to the lower end of about $11,000 for an appendectomy. If you look above at the example policy, youll see that for the entire coverage term an appendectomy will be given a $2,500 coverage benefit. Even though your plan has a deductible, coinsurance, and max out of pocket; theres a specific limitation for appendicitis. With this knowledge, the insured will be left an $8,500 bill as an out of pocket expense! Keep in mind; these numbers are on the low end with no complications.Of course, its always better to have health insurance instead of going uninsured. With insurance, that remaining $8,500 for the appendectomy may negotiate to a lower bill. Policygenius.com does a great job explaining the functionality of network negotiated rates. Without insurance, you would be paying the almost full retail price for your medical surgery, which is a terrifying thought!
Can I Just Purchase Insurance Myself?
You can, but should you?Theres a dark stain over the insurance industry for consumers searching for quotes online. Families and individuals are aware they need to carry health and life protection but dread entering their information online, consequently experiencing the bombardment of phone calls that follow. Its so bad some people would instead go without coverage than speak with a broker over the phone. When in reality, all it takes is working smarter, not harder.Some people will advise you to buy your own auto, home, health, life, or any other insurance. They will tell you horror stories about the number of calls youll receive if you submit information online. They will present a convincing argument, and youll be tempted to accept their advice. I urge you to resist that temptation.Its no surprise that many people are turning to self quoting websites and applications. The appeal is undeniable. Theres nothing inherently wrong about this approach, and it does save the consumer the headache of having to speak to countless agents. However, should you buy insurance without speaking to a licensed broker? Its fine to quote yourself and see whats out there in terms of options, but then proceeding to purchase that insurance without educational guidance is extremely risky for the consumer. When you use past experiences, personal knowledge, and stories heard from friends to make an informed decision on your insurance; the result tends to be medical debt or bankruptcy.A licensed agent or broker has a fiduciary responsibility to you. They are mandated by state and federal law to undergo licensed certification. While you may not have had pleasant experiences in the past, having a broker perform a needs analysis to personalize the policy is a better alternative. Just like any other profession, some paid attention during class, and others did not. It isnt appropriate to blanket statement all insurance brokers as untrustworthy.Heres your solution to avoid entering your information online. Instead, reach out to family members and friends. Ask them whom they use for their insurance needs and their experience with their broker. If you cant find a family or friend who uses a local agent or broker; reach out to colleagues and people within your circle of influence for guidance. By doing so, you are acquiring a real person who is aware of your personal needs and whom others trust. Its an ideal win-win situation between a trusted broker and client. You leave feeling confident in your policy because you are informed, and youve supported a local small business owner and their family. It may not be the fastest solution, but should it?When the world is more efficient, were all happy. Quicker load times, faster test results, high-speed internet. The need for convenience and expedience permeates everything we do. Theres relief in knowing you can quote and compare prices without receiving dozens of calls.However, when you go to purchase your insurance slow down, consult a professional, ask questions, and then fill out your application with the knowledge youre protected and supported.