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Making Sense Out of Medicare and Medicaid

Medicare and Medicaid can be confusing issues, particularly if you have recently taken over caregiving responsibilities for your parent and are starting from square one. Generally, if your parents are over 65, and are eligible to receive Social Security or Railroad Retirement Board benefits, they should be eligible to receive Medicare. Additionally, low-income seniors may also be eligible for Medicaid.


The following article is designed to guide you as you wade through the process of Medicare and Medicaid, and will cover key topics including navigating through the maze of Medicare, when to apply, what happens if your parent is denied coverage and additional resources for you to access.


What is the difference between Medicare and Medicaid?

Medicare is a federally-funded social insurance program that offers coverage for necessary inpatient and outpatient medical care, certain typies of physician-ordered durable medical equipment, and short-term rehabilitation or skilled nursing care following a qualifying hospital stay. Under the “Original” Medicare plan, participants pay deductibles as well as co-pays or co-insurance.


In contrast, Medicaid is funded by both federal and state governments and is designed to provide coverage for medical care and to act as a “supplemental” insurance plan for seniors with limited resources and income, and for adults with disabilities.  Many states also utilize their Medicaid programs to help pay for long-term care and in-home care for limited-income seniors. Eligibility for the Medicaid program is income-based, and income eligibility guidelines vary from state to state.  Applicants should their Area Agency on Aging or local Medicaid office. Individuals who are eligible for both Medicaid and Medicare may be eligible to receive help with their Medicare Part B premiums, deductibles, and co-insurance, as well as with prescription drug costs.


How do I know if my loved one is eligible for Medicare?

Medicare covers nearly everyone 65 or older and receiving Social Security or Railroad Retirement Board benefits, and also provides health care coverage for those under 65 who are permanently disabled or who have been diagnosed with end-stage renal disease.


What are the different Medicare options?
Until the mid-1990s there was essentially one program for everyone enrolled in Medicare. Today, there are alternatives to Original Medicare including Medicare Advantage Plans and the Program of All-Inclusive Care for the Elderly (PACE).  There are also optional prescription drug plans and Medicare supplement plans that participants may wish to join. Some of the plans go by the cryptic and undescriptive names of Part A, Part B, Part C and Part D. Part A is considered the “hospital insurance” portion of Original Medicare and includes coverage for medically necessary inpatient care. Part B covers medically-necessary outpatient care, doctor visits, and durable medical equipment. Part C is synonymous with Medicare Advantage plans which are offered through private insurance companies and replace Original Medicare coverage. The privatized plans market themselves by saying they cost less and provide more services, but the jury is out on whether or not those claims are actually true. "Frequently when people become sick or want to see a particular specialist they can run into a problem if their provider is not in their plan," says Judith Stein, attorney and executive director of the Center for Medicare Advocacy.


The easiest one to remember is Part D, the Prescription Drug Plans. There are many plans and pricing options to choose from under Part D, so it is important to carefully evaluate your parents’ prescription drug needs when selecting a Part D plan. Like Medicare Advantage plans, Part D plans are issued by private insurance companies authorized to sell their plans in specific areas.


Medigap is yet another options for Medicare enrollees to consider.  Medigap plans, which are also known as Medicare supplemental plans, can help to cover the cost of deductibles, co-pays, and co-insurance for subscribers to the Original Medicare program.  There are twelve standardized Medigap plans (A through L), and the type of coverage provided by each plan is determined by the Medicare program.  Despite this, monthly premiums can vary tremendously from one issuer to the next, so it pays to research all of the options before selecting a Medigap plan.


When to apply
Initially, people are eligible to enroll for Medicare three months before turning 65 and should do so through the Social Security office. Additionally,  between November 15 and December 31, current Medicare enrollees can re-evaluate their coverage options and make a changes such as adding or changing prescription drug plans or switching to a privatized managed care program. Then they cannot make a change to their plan until the following November 15.
If your parent is denied coverage


Unfortunately, people are denied coverage for medical services every day. The Center for Medicare Advocacy fields more than 7,000 calls each year from people who need help getting the coverage they are entitled to.
 

Here are some tips for ensuring Medicare coverage: 

     
  • Make sure your physician will go to bat for you. "Physicians often will help out," Stein says. "They can be your best advocate."
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  • Educate yourself on standards for coverage. Medicare may be denied based on a definition of a condition, for example if your parent is injured and homebound.
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  • Be aware of the timing. If your parent is enrolled in the traditional Medicare program and you need to contest a denial, the system is required to complete evaluations in 60- to 90-day stages. "The whole process might take up to a year, but if you’re looking to recover a big loss in coverage it is worth it," says Stein.
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  • Contact the Center for Medicare Advocacy. Founded by Stein in 1986, the center is a rich resource for assistance and information.


     
  • The Center for Medicare Advocacy fields more than 7,000 calls each year from people who need help getting the coverage they are entitled to.
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  • Each year, between November 15 and December 31, Medicare enrollees can re-evaluate their plan and make a change.