What Are The Disadvantages Of Medicaid
Disadvantages of Medicaid Lower reimbursements and reduced revenue. Every medical practice needs to make a profit to stay in business, but medical practices that have a large Medicaid patient base tend to be less profitable. Administrative overhead. Extensive patient base. Medicaid can help get new practices established.
Medicare Part A B C D
- Medicare Part A covers in patient and Hospice care.
- Part B covers outpatient services.
- Part C is an option meant to grant plans or parts of plans that will lower the cost to the government which while continuing to allow patients to choose plans where the benefits meet their needs.
- Part D covers prescription drugs
Medicare will pay for short periods of rehab stays in a nursing after surgeries or injuries. I can also pay for rehab/therapy at home for a restricted period of time if ordered by a doctor.
Medicare will Not cover:
- Long term care at a nursing home
- Residential care homes
- Any long-term care
Does Medicare Pay For A Nursing Home
Unfortunately, Original Medicare doesnt cover the cost of a long-term stay at a nursing home, but certain parts of Medicare can pay for medically necessary or essential services at nursing homes. Some of these services include meal preparation, prescription drugs, durable medical equipment, counseling, and other services. Overall, Original Medicare covers short-term visits, but not long-term stays.
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Does Medicaid Pay For A Nursing Home
Medicaid pays for long-term care in a nursing home for seniors who meet the programs requirements. Seniors must relinquish any income aside from a limited monthly personal allowance, usually under $75 to be eligible for Medicaid coverage, which will then cover nearly all associated costs, including a seniors room and health care services.
Other Sources Of Data On Medicaid Enrollment
National Survey Data
Current Population Survey : Provides demographic detail but cannot provide estimates of state-level coverage.
National Health Interview Survey : Estimates both coverage status and length of time with coverage at time of interview but states must be combined to produce reliable annual estimates.
Medical Expenditure Panel Survey : Contains detailed information covering two full calendar years that can be broken down into census regions .
Survey of Income and Program Participation : Includes health care coverage status as well as disability status but cannot provide annual estimates.
Aggregate-Level Administrative Data
Medicaid Budget and Expenditure System : Aggregate enrolled data available quarterly, can be linked to claims data but lacks demographic detail.
Centers for Medicare & Medicaid Services Performance Metric Data: Updated monthly and includes details by state and program.
Individual-Level Administrative Data
Medicaid Statistical Information System : While not publicly available, can link enrollment and spending but lacks demographic characteristics.
Census Bureau, Health Insurance
Moving Medicaid Data Forward, Forum: Medicaid EnrollmentOverview and Data Sources
Medicaid Pocket Primer
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Whos Eligible For Medicare And Medicaid
The requirements are going to be similar, but they are going to be state-specific, McDowell says in regards to Medicare and Medicaid eligibility markers.
Heres an overview of federal guidelines:
- Medicare recipients must be age 65 or older. Individuals receiving Social Security or Railroad Retirement Board benefits are also eligible, along with people whove received Social Security or Railroad Retirement Board disability benefits for at least two years. Kidney transplant patients and people undergoing kidney dialysis treatment are also eligible. The Social Security website is a resource that can help seniors review requirements and start the Medicare application process.
- Medicaid recipients must meet certain income thresholds and asset limitations based on their state of residence. Though income requirements vary in each state, theyre typically based on being within 133% of the poverty level. States can also deem individuals medically needy, meaning they exceed the standard income but have significant medical expenses. If your family member is planning to apply for Medicaid, its a good idea to contact your state medical assistance office for more details. Depending on where you live, Medicaid programs may be referred to as auxiliary grant, elderly waiver, or frail elderly waiver programs.
Which States Have Pace / Life Programs
While Medicare benefits are the same for recipients around the country, Medicaid benefits vary significantly depending on ones state of residence. This means, unfortunately, that PACE is not available in every state. In January 2022, PACE/LIFE benefits were available in 30 states.
These are the states with PACE/LIFE programs: Alabama, Arkansas, California, Colorado, Delaware, Florida, Iowa, Indiana, Kansas, Louisiana, Massachusetts, Maryland, Michigan, North Carolina, North Dakota, Nebraska, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia, Washington, and Wisconsin.
Moving for Benefits
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Does Medicare Cover Memory Care
Much like with assisted living, Medicare wont pay for rent or board in memory care facilities. However, Medicare does cover many costs associated with dementia treatment, such as equipment and supplies designed to counter common dementia safety risks. Seniors with dementia generally experience a loss of balance and coordination in the early and middle stages of the disease, and Medicare pays for resources like walkers and grab bars.
Under some Medicare Advantage plans , families can receive cost assistance with GPS trackers for elderly loved ones, devices which help avoid the dangers of wandering and disorientation either in a community setting or at home.
Medicare Part D, which provides prescription drug coverage, also assists with common dementia care costs. Though theres no FDA-approved medication known to cure Alzheimers or other forms of dementia, Medicare Part D helps pay for medications that may stave off the conditions progression.
How Medicaid Can Help With Medical Expenses For Seniors
Larryâs elderly father is struggling to make ends meet. After moving into a senior apartment complex after the death of his wife and living largely off of his Social Security income, his fatherâs finances are tight. Larry is helping to find ways to pay the monthly rental fee, buy groceries, and cover co-pays for his heart medications and his Medicare coverage. His father needs assistance beyond Medicare to cover his growing medical expenses, and Larry has heard about Medicaid, but heâs not sure where or how to find out if his father is eligible.
His fatherâs situation is faced by many seniors the Kaiser Family Foundation reports that one in four Medicare beneficiaries spent 30% or more of their income on health expenses in 2006. Making sense of Medicaid can be difficult for seniors and their caregivers. In the midst of an already confusing time, family caregivers often find confusion in the midst of Medicaid forms and filings. However, there are resources available to navigate Medicaid.
- The Area Agency on Aging in your area is a good first stop to learn more about the process for applying for Medicaid. To find your local agency, you can look on the National Association of Area Agencies on Aging website, which lists agencies alphabetically by state.
Additional Resources
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Medicaid Adults 65 And Older & People With Disabilities
The Medicaid program provides comprehensive medical coverage to seniors and people with permanent disabilities. People receiving SSI benefits automatically receive Medicaid. Seniors and people with disabilities who are receiving Social Security Retirement or Disability benefits and have income/resources that exceed the SSI limits may be eligible for Medicaid under the rules described in this section.
Note: People with disabilities who are waiting for a decision on eligibility for SSI or Social Security Disability Insurance benefits may be eligible for Medicaid under the MAGI category.
Who Qualifies?
- 65 and older.
- People who have a severe physical and/or mental disability that has lasted or will last longer than one year or will result in death and prevents any substantial gainful employment.
- Must be a citizen or eligible immigrant. Eligible immigrants include refugees or persons granted asylum. Lawful Permanent Residents who entered the U.S. on/after 8/22/96 must be in status for at least 5 years. In addition, immigrants who were in lawful status in the U.S. before 8/22/96 and lived in RI at some time before 7/1/97 may be eligible for coverage.
Income and Resource Limits
How to Apply
You can apply on-line at healthyrhode.ri.gov. You can also request a paper application from a DHS office by calling: 1-855-697-4347 or by downloading the form from the EOHHS website at:
For more information on Medical Assistance see the EOHHS website.
What Is Medicare Advantage
Medicare Advantage is also known as Medicare Part C. These plans are administered by private medical insurance companies who are in contract with Medicare to provide benefits. Parts A and B are combined under one policy.
Medicare Advantage must cover all Medicare-approved services, and some companies may offer additional benefits, like vision, hearing, and dental options.
The medical insurance plans offered through private companies can include:
Medicare Part D offers prescription drug coverage.
Private medical insurance companies offer part D plans as standalone policies.
Coverage for prescription medication can be included within Medicare Advantage plans. However, a person cannot opt for a standalone policy in addition.
Medicare Part D is an optional benefit. If a person decides not to enroll when they are first eligible, a late enrollment penalty may occur.
An individual can find a prescription drug plan within their local area using Medicares online Find a Medicare Plan website.
Medicare plans that help pay for some out-of-pocket expenses are known as supplementary insurance or Medigap plans.
Types of out-of-pocket expenses covered may include:
- copayments
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What Is The Difference Between Medicare And Medicaid
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How Mepd Services Are Provided
If you’re an adult with a disability and qualify for MEPD, these services are typically provided by STAR+PLUS. You will choose a STAR+PLUS health plan from the ones available in your service area.
If you have a child with a disability who qualifies for MEPD, these services are typically provided by STAR Kids. You will choose a STAR Kids health plan from the ones available in your service area.
You might also be enrolled into traditional Medicaid. Traditional Medicaid just means the state pays your doctors, nurses and other caregivers directly.
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How The Programs Differ
Medicare is an insurance program while Medicaid is a social welfare program.
Medicare recipients get Medicare because they paid for it through payroll taxes while they were working, and through monthly premiums once theyre enrolled.
Medicaid recipients need never have paid taxes and most dont pay premiums for their Medicaid coverage .
Taxpayer funding provides Medicaid to eligible needy people in a manner similar to other social welfare programs like Temporary Assistance for Needy Families Women, Infants and Children and the Supplemental Nutrition Assistance Program.
Both Programs In A Nutshell
Both of these programs were created by the federal government to provide healthcare to the elderly, disabled, and families with financial needs. This means that the US government is responsible for providing protections and regulations for these programs.
Medicaid is entirely financed through the federal government. The state governments have no role in Medicare but do have a large amount of discretion with Medicaid.
Medicare is based on age, social security, and time you have been in the workforce. Medicaid, on the other hand, is an assistance-based program that takes your income and assets into account to determine eligibility.
Now that you have a broad idea of the differences between the two, lets get into some more detailed explanations of each program.
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Dual Eligibles: Having Both Medicare And Medicaid
Some seniors qualify for Medicare and Medicaid and are referred to as dual-eligible beneficiaries. In addition to Medicare, an elder can receive either partial or full Medicaid benefits. Medicare remains the primary source of coverage and payment for health care services while Medicaid either helps to pay for out-of-pocket costs or offers full benefits as a secondary or even tertiary payer.
Will Medicaid Pay For Assisted Living
Medicaid typically pays for some but not all assisted living services. Families and seniors can expect help with costs related to medical treatments and personal care services, reducing their overall bill. However, Medicaid often wont cover the total price of room and board in an assisted living community. In most states, Medicaid can be used to pay for the following:
- Help with ADLs like toileting, mobility, and dressing
- Home health services, which may be provided in an assisted living community
- Physical, occupational, or speech therapy
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Majority Of People Covered By Medicaid And Similar Programs Are Children Older Adults Or Disabled
Medicaid provides health insurance coverage to more people than any other single program in the United States, with coverage for low-income children, adults, seniors, and those with disabilities.1 As of March 2017, there were 74 million Medicaid and Childrens Health Insurance Program enrollees, of which nearly 36 million were enrolled in CHIP or were children enrolled in Medicaid, according to the Center for Medicaid and CHIP Services.2
For a more detailed breakdown of people covered by Medicaid and other means-tested health insurance programs , we turned to the American Community Survey .3
As shown in the table below, children and youth represent nearly half of all people covered by means-tested public health insurance in the United States. Adults ages 65 and older, many of whom are low-income and participate in Medicaid to supplement Medicare, represent nearly 11 percent. Disabled and institutionalized adults account for another 14 percent, and women who have given birth in the past year represent just under 2 percent. These vulnerable groups account for more than seven in 10 participants in means-tested health insurance programs. Of those remaining, 12 percent work full time or part time. In short, Medicaid and CHIP participants are among the most vulnerable members of the U.S. population.
Table: The Majority of Publicly Insured Individuals Are Children, Older Adults, or Disabled.
Do All Nursing Homes Accept Medicaid
A majority of nursing homes accept Medicaid however, this is also largely dependent on the state you reside in. To avoid complications with payment and coverage, Id recommend checking with your nursing home facility to see if they are a Medicaid-certified nursing facility. If it is, then you should be eligible for coverage under the Medicaid skilled nursing facility.
In the event that you find out the nursing home is not Medicaid-certified, you would have to transfer to a nursing facility thats covered by Medicaid.
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How Much Will Medicaid Pay For Nursing Home Care
For qualifying individuals, Medicaid picks up most of the tab for nursing home care, paying an average of 45 percent to 65 percent. However, coverage is largely dependent on a variety of factors such as financial status, the state you reside in, and the level of care needed.
Medicaid coverage amounts may vary from state to state, depending on the demand for nursing home care coverage. For example, the average cost of nursing home care in the state of California is on the higher end at $304 a day, compared to Texas at $165. This greatly impacts the coverage and benefits you can receive from Medicaid to offset the costs of nursing home care.
Implications For The Future
The three decades of experience with Medicare as a primary insurer and Medicaid as a supplement for the low-income elderly demonstrate the importance of both basic coverage for all elderly people and additional financial assistance for low-income elderly people. For those in the elderly low-income population jointly covered by Medicare and Medicaid, access to care, financial protection, and satisfaction with the cost of medical care are all notably higher than for low-income elderly who depend solely on Medicare. With the universal base of Medicare as a building block for health care coverage, the elderly poor and near-poor with Medicaid supplementation are able to access mainstream medical care without severe financial burden.
To assure Medicare’s adequacy for coverage in the future, it is important to maintain assistance with financial obligations and additional benefits that Medicaid provides today. It is critical to either maintain the Medicare-Medicaid partnership for the low-income elderly or to provide direct federal assistance to supplement Medicare for the elderly poor. Without such guarantees, Medicare’s notable progress in reducing gaps in service use between poor and non-poor elderly could be undone and millions of low-income elderly Americans could have their access to medical care compromised.
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Medicaid Works For Seniors
Medicaid provides essential care for 7 million seniors. Medicaid covers nursing home care and other long-term services and supports, as well as other medical care and supportive services that Medicare doesnt cover, which help many low-income seniors and people with disabilities stay independent and healthy. It also covers premiums, deductibles, and cost-sharing for Medicare beneficiaries.
Cutting Medicaid or radically changing its financing structure for example to a per capita cap as in recent congressional Republican proposals to repeal the Affordable Care Act would threaten the essential services and other assistance that seniors rely on to maintain their health and independence. Instead of placing a cap on Medicaid, federal policymakers should support positive state innovations that improve coverage for seniors.
