How To Improve Health Care For People With Medicare And Medicaid
Roughly 11 million poor Americans over 65 have the most severe health needs: theyre called dual eligibles, because theyre eligible for Medicares medical benefits as well as for Medicaids long-term care benefits. Problem is, as Dr. Bruce Chernof, The SCAN Foundations president and CEO, says: Medicare and Medicaid dont talk to each other, or work with each other, very well.
That, in turn, is a severe problem for the dual eligibles, caught between the two health programs and, consequently, often receiving less than optimal care. Yet these same people account for 40% of Medicaid spending and 27% of Medicare spending.
Dual Eligibles With Chronic Conditions
Theyre also more likely to have multiple chronic conditions, plus whats known as functional impairment difficulties with activities of daily living, such as toileting, bathing, walking and getting dressed. And this combination is expensive for taxpayers, so theres a big-picture reason to care: In 2015, Medicare per-beneficiary expenditures for individuals with multiple chronic conditions were roughly seven times higher than for those with one or no chronic conditions, according to a recent Bipartisan Policy Center report, Improving Care for High-Need, High-Cost Medicare Patients.
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Medicare And Medicaid Dual Eligibility
When youre dual eligible, Medicare is primary and Medicaid is secondary. Basically, Medicaid fills in the coverage gaps the way a Medigap plan does. When youre dual eligible, you also may qualify for a Medicare Savings Program.
When you have Medicare, Medicaid, and a Medicare Savings Program, you have full health-care coverage for which you pay nothing out of pocket.
General Fund Revenue As A Share Of Total Medicare Spending
This measure, established under the Medicare Modernization Act , examines Medicare spending in the context of the federal budget. Each year, MMA requires the Medicare trustees to make a determination about whether general fund revenue is projected to exceed 45 percent of total program spending within a seven-year period. If the Medicare trustees make this determination in two consecutive years, a “funding warning” is issued. In response, the president must submit cost-saving legislation to Congress, which must consider this legislation on an expedited basis. This threshold was reached and a warning issued every year between 2006 and 2013 but it has not been reached since that time and is not expected to be reached in the 20162022 “window”. This is a reflection of the reduced spending growth mandated by the ACA according to the Trustees.
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Can One Have Dual Eligibility For Both Medicare And Medicaid
Yes, Medicare and Medicaid are not mutually exclusive programs. Persons who are eligible for both are referred to as having Dual Eligibility, Dual Eligibles, or often simply Duals. Medicare is the first payer of covered benefits, while Medicaid is the secondary payer. Typically, Medicaid will pay for Medicare premiums and co-payments for dual eligibles. In fact, many states have special programs intended to make it easier for seniors to manage their dual eligibility status as it can be confusing to know where to turn for what services. This is generally in the form of managed care.
There are also programs called Medicare Saving Programs for low-income seniors that dont quite qualify for Medicaid.
Conducting Research With Medicaid Data
Various data sources are available to analyze the Medicaid program. Administrative data provide point-in-time counts and allow users to analyze trends in enrollment and program spending across time, but are limited in their ability to describe the people participating in the program. These data are not always available for public use or produced in a timely manner, making it difficult for researchers or policymakers to understand the programs current effectiveness.
Conversely, surveys provide social and demographic data such as age, sex, education, and race/ethnicity, which can help researchers and policymakers better understand Medicaid recipients. Another added benefit is the capability for deeper analysis by adding population data as denominators to calculate rates and percentages.
There are also limitations to using survey data as a source for Medicaid-related research. Survey data tend to underestimate participation in social programs.4 Historical data may not be available, and national surveys may not accurately measure participation in state-specific programs. Despite these limitations, we used data from the ACS for this analysis because it provides detailed demographic data and is a nationally representative sample of the population.
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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
Is Medicare Or Medicaid For Old People
- Asked May 8, 2014 in
Contact Jim Winkler Contact Jim Winkler by filling out the form below
Jim WinklerPROCEO/Owner, Winkler Financial Group, Houston, TexasThat is a great question! I guess the answer depends upon what your definition is of old. Medicare is a program that was designed to provide seniors 65 or older the opportunity to receive affordable health care. There are instances when you can receive it before turning 65, but that is the usual standard. Medicaid is different. It is a program designed to help elderly or low income people find affordable health care. Medicaid differs from Medicare in that it is State run, not Federally, so there can be great differences from state to state in costs and benefits. I hope that answers your question, if you would like more detail, contact me, I’m happy to help. Thanks for asking!Answered on May 8, 2014+0
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What Does Medicare Cover For The Legally Blind
Medicare benefits are the same whether you qualify based on age or disability. Anyone under the age of 65 who is legally blind and who qualifies for Medicare coverage will have access to the same benefits as those over the age of 65 who do not have a disability.
Original Medicare does not include any benefits that are specific to the blind. Medicare does not cover white canes , service dogs or any vision assistive equipment or low-vision devices.
If you are legally blind, however, you might qualify for a certain type of Medicare Advantage plan called a Special Needs Plan . These plans are designed for people with specific health conditions or financial circumstances and include a set of benefits tailored to those needs. A Medicare Advantage Plan, and particularly a Special Needs Medicare Advantage Plan, may provide coverage for white canes and vision assistive equipment.
Medicare Eligibility At Age 65
- You are at least 65 years old
- You are a U.S. citizen or a legal resident for at least five years
In order to receive premium-free Part A of Medicare, you must meet both of the above requirements and qualify for full Social Security or Railroad Retirement Board benefits, which requires working and paying Social Security taxes for at least 10 full years .
Learn more about Medicare eligibility at and before age 65 by referring to this helpful chart and reading more information below.
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Reimbursement For Part A Services
For institutional care, such as hospital and nursing home care, Medicare uses prospective payment systems. In a prospective payment system, the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care. The actual allotment of funds is based on a list of diagnosis-related groups . The actual amount depends on the primary diagnosis that is actually made at the hospital. There are some issues surrounding Medicare’s use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of “upcoding”, when a physician makes a more severe diagnosis to hedge against accidental costs.
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This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply. For more information, call UnitedHealthcare Connected® Member Services or read the UnitedHealthcare Connected® Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.
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Can You Qualify For Medicare If You Are Legally Blind
If you collect disability benefits from Social Security or the Railroad Retirement Board for 24 consecutive months, you can begin receiving Medicare coverage beginning with your 25th month.
The Social Security Administration determines eligibility for disability benefits and defines legally blind as:
Vision that cant be corrected to better than 20/200 in your better eye, or if your visual field is 20/200 in your better eye, or if your visual field is 20 degrees or less in your better eye for a period that lasted or is expected to last at least 12 months.
Pathways To Full Medicaid Eligibility Based On Old Age Or Disability
States generally must provide Medicaid to people who receive federal Supplemental Security Income benefits.7 To be eligible for SSI, beneficiaries must have low incomes, limited assets, and an impaired ability to work at a substantial gainful level as a result of old age or significant disability. The SSI federal benefit rate is $750 per month for an individual and $1,125 for a couple8 in 2018,9 which is 74 percent of the federal poverty level . The effective SSI income limit is somewhat higher than 74% FPL in four states, due to state supplemental payments and/or additional income disregards: 80% FPL in Idaho, 83% FPL in New York and Wisconsin, and 87% FPL in Missouri . Box 1 provides more information about disregards. SSI beneficiaries also are subject to an asset limit of $2,000 for an individual and $3,000 for a couple.
Seniors and people with disabilities up to 100% FPL
Over 40 percent of states elect the option to expand Medicaid to seniors and people with disabilities whose income exceeds the SSI limit but is below the federal poverty level 12 .13 Eighteen of these states set the income limit at 100% FPL, the federal maximum for this pathway. In the other three states electing this option, the eligibility limit is 80% FPL in Arkansas, 81% FPL in Virginia, and 88% FPL in Florida. Twenty of the 21 states electing this option cover both seniors and people with disabilities, while Arkansas only covers seniors.
Medicaid Eligibility And Costs
The federal and state partnership results in different Medicaid programs for each state. Through the Affordable Care Act , signed into law in 2010, President Barack Obama attempted to expand healthcare coverage to more Americans. As a result, all legal residents and citizens of the United States with incomes 138% below the poverty line qualify for coverage in Medicaid participating states.
While the ACA has worked to expand both federal funding and eligibility for Medicaid, the U.S. Supreme Court ruled that states are not required to participate in the expansion to continue receiving already established levels of Medicaid funding. As a result, many states have chosen not to expand funding levels and eligibility requirements.
Those covered by Medicaid pay nothing for covered services. Unlike Medicare, which is available to nearly every American of 65 years and over, Medicaid has strict eligibility requirements that vary by state.
However, because the program is designed to help the poor, many states have stringent requirements, including income restrictions. For a state-by-state breakdown of eligibility requirements, visit Medicaid.gov and BenefitsCheckUp.org.
Poverty And Illness In The Elderly Population
Despite general improvements in the economic situation of the elderly population over the last 3 decades, many elderly Americans continue to struggle to pay living expenses on low or modest incomes. Forty-one percent of the Nation’s 31 million elderly people living in the community have incomes below twice the Federal poverty level and 1 in 5 are poor or near-poor .
In 1994, the FPL was $7,100 per year in income for a single elderly adult and $9,000 for an elderly couple. Twelve percent of the elderly population3.7 million people had incomes below the poverty level and another 7 percent2.2 million people were near-poor with incomes between 100 and 125 percent of FPL . Together, these 5.9 million poor and near-poor people comprise Medicare’s non-institutionalized low-income elderly population. Another 1.4 million elderly reside in nursing homes and receive assistance from Medicaid .
Distribution of Elderly, by Poverty Level: 1994Percent of the Elderly Who Are Low-Income, by Age, Sex, and Race: 1994Characteristics of Elderly Medicare Beneficiaries: 1992Percent of Elderly Medicare Beneficiaries Reporting Fair or Poor Health: 1992Percent of Elderly Medicare Beneficiaries With Selected Conditions: 1992Percent of Elderly Medicare Beneficiaries Needing Help With ADL Limitations: 1992
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Quality Of Beneficiary Services
A 2001 study by the Government Accountability Office evaluated the quality of responses given by Medicare contractor customer service representatives to provider questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%. Since then, steps have been taken to improve the quality of customer service given by Medicare contractors, specifically the 1-800-MEDICARE contractor. As a result, 1-800-MEDICARE customer service representatives have seen an increase in training, quality assurance monitoring has significantly increased, and a customer satisfaction survey is offered to random callers.
Additional Ways To Get Help With Medicare Costs
If you are not considered low income and therefore not eligible for Medicaid, you can enroll in a Medicare Advantage plan also known as Part C. When you opt for Part C, a private carrier pays for your health care instead of Medicare.
Medicare Advantage plans all come with their own cost-sharing. A rule of thumb: the lower your monthly premium, the higher your cost-sharing. You still need to set aside extra funds to cover your medical costs in order to protect your retirement savings.
The other option to help cover cost-sharing is to enroll in a Medigap plan. Medigap plans come with a monthly premium, but they cover significantly more than a Medicare Advantage plan. They also do not have all the limitations Medicare Advantage plans come with.
Did You Know: To learn more about the differences between these types of coverage, read my guide: Medicare Advantage vs. Medigap.
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Medicaid Cuts Would Jeopardize Coverage For Seniors
Millions of Medicaid beneficiaries would lose coverage, and hundreds of billions of dollars in federal Medicaid funding would be cut, under congressional proposals to impose a rigid and increasingly inadequate cap on federal funding for state Medicaid programs. Such proposals would effectively end states option to expand Medicaid under the ACA, threaten health care for large numbers of low-income Medicaid beneficiaries, and leave seniors particularly at risk of going without needed care.
Such Medicaid cuts would:
This report was prepared with support from the Commonwealth Fund.
The Solvency Of The Medicare Hi Trust Fund
This measure involves only Part A. The trust fund is considered insolvent when available revenue plus any existing balances will not cover 100 percent of annual projected costs. According to the latest estimate by the Medicare trustees , the trust fund is expected to become insolvent in 8 years , at which time available revenue will cover around 85 percent of annual projected costs for Part A services. Since Medicare began, this solvency projection has ranged from two to 28 years, with an average of 11.3 years. This and other projections in Medicare Trustees reports are based on what its actuaries call intermediate scenario but the reports also include worst-case and best-case projections that are quite different .
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