Having worked in the Senior Healthcare market in one form or another for over 20 years, I am surprised that I can still get confused at the difference between Medicare and Medicaid. It is not easy for everyone to grasp. I recently cultivated a wonderful networking relationship with a Medicaid Specialist who works for a reputable elder law firm. During our discussions, we realized there are a lot of myths and mysteries related to Medicare and Medicaid. Now, is this a riveting topic? No, but it is important to a lot of people! So, let’s do a brief review of the basics to help distinguish between these two important services.
Federal (Medicare) vs State (Medicaid)
Medicare is a federal health insurance program controlled and operated by CMS – Center for Medicare and Medicaid Services. Medicare is funded by taxes everyone pays throughout their working life and beyond. Everyone is entitled to Medicare benefits when they turn 65, regardless of income or health status. Some individuals do qualify before the age of 65 based on certain medical conditions or disabilities. Medicare covers medically necessary care and treatment. Traditional Medicaid, however, is a program that covers healthcare expenses but also social service needs for individuals below a certain income threshold. Medicaid recipients can be any age from birth to death. It is jointly funded by each state and the federal government through a federal matching program.
Nursing Homes – Short Term Rehab vs Long Term Care
The largest cost to Medicaid for the State of Indiana is for those who live in a long-term care facility. Traditional Medicaid pays for long-term custodial care and services for those that cannot be cared for in a home setting. A major distinction here is that Medicare does NOT pay for long-term care. This is often confusing. Medicare only pays for a very short-term rehabilitation stay in a facility. If you need long term care in a nursing home but have income and assets, you would have to pay privately for room and board. This can be extremely expensive (on average $9,000 - $12,000 per month depending on private room and/or level of care required). This is where a good Elder Law Attorney can be extremely helpful. They can protect assets and assist in pursuing Medicaid to pay this cost. However, I cannot stress enough how important it is to consult with a firm early on – not when you or your loved one is already institutionalized. Although they can help in that situation, it is best to plan ahead!
Dual Eligible
As stated above; to qualify for Medicare, you must be 65 years of age or have certain health conditions or disabilities. Being eligible for Medicare has nothing to do with income. Medicaid, however, is an income-based service. You can be any age to qualify for Medicaid but must meet certain low income and asset thresholds. What makes things more confusing at times is that some individuals qualify for both – Medicare and Medicaid. We call this ‘Dual-Eligible’. In the insurance world, this is where those pesky commercials and sales tricks can get you. Dual-Eligible individuals qualify for special plans called DSNP or Dual Special Needs Plans. Those include lots of extra benefits such as money for groceries, utilities, large over-the-counter allowances and more. The advertisements unfortunately make it seem as though anyone can have those plans with those perks. This is not true, so do not be fooled!
Pathways for Indiana Program
Newly implemented as of July 1st, 2024, the Indiana Pathways program is the new way Indiana is managing Medicaid for those 60 years and older. Indiana has contracted with three large insurance companies – Anthem, Humana and UnitedHealthcare to manage all Medicaid members 60 years and above. The traditional Medicaid card which said ‘Hoosier Healthworks’ will be replaced by the chosen Pathways program card by one of the three companies. They will provide a care management team to streamline all services available to assist members in managing their healthcare needs and other social service needs. The goal is to keep people living as independently as possible rather than in nursing homes. While the roll out is likely to be a bumpy road, the program’s goals and intentions are good! Let CDI know if you would like more information or have questions. We can help direct you to where you need to go!
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
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