Making Sense of Medicare & Medicaid

Navigating medical costs and coverage can be confusing. Need some guidance? Let this overview steer you through:

Medicare and Medicaid are two separate government programs created in 1965 by President Lyndon Johnson as part of a social commitment to meeting individual health care needs.

parts-of-medicare-from-boomer-benefits-comMEDICARE
Medicare is the federal government’s health insurance program for people age 65 or older, and those with severe disabilities. Medicare covers some services in a nursing facility. Medicare does not cover long-term care costs.

Medicare has several parts:

Part A helps pay for:

  • Hospital Care
  • Skilled Nursing or Rehabilitation Care (in a skilled nursing facility)
  • Home Health Care
  • Hospice Care

Part A provides up to 100 days per year in a skilled nursing facility if you have a 3-day qualifying stay in a hospital and require services meeting the definition of “skilled” in the Medicare guidelines. Part A pays 100% for days 1-20; there is a co-pay for days 21-100. Most Medicare co-insurance plans pay the co-pay.

Part B is an optional medical insurance for which you pay a monthly premium that covers many outpatient services. Part B insurance primarily covers outpatient services but may cover some services while a person is a Resident in a nursing facility. For example, someone who does not have a 3-day hospital stay prior to admission and is “private pay” for their room & board, can have therapy services billed under Part B.

Part C is known as Medicare Advantage, or private insurance. The cost of Advantage plans varies by carrier, county of residence, and plan selected. To enroll in a Part C plan, you must first be enrolled in both Parts A and B.  Medicare Part C is voluntary.  Many people prefer traditional Medicare supplements and do not want a Part C Medicare Advantage plan.

Part D covers prescription drugs when you choose a carrier and enroll in their drug plan. Most states have many plans to choose from and people often work with an agent to navigate the many options.


MEDICAID
Medicaid is a public insurance program providing health care coverage to low-income families and individuals, including children, parents, pregnant women, seniors, and people with disabilities; it is funded by the state and federal government.

Each state operates its own Medicaid program within federal guidelines. Because the federal guidelines are broad, states have a great deal of flexibility in designing and administering their programs. As a result, Medicaid eligibility and benefits often vary widely from state to state.

Medicaid does not provide health care directly. Instead, it pays hospitals, doctors, nursing homes, managed care plans, and other health care providers for covered services that they deliver to eligible patients. (Health care providers are not required to participate in Medicaid, and not all do.)

  • Medicaid covers more than 60 percent of all nursing home residents and 40 percent of costs for long-term care services and supports.
  • Medicaid provides health coverage for one in five Americans, or 97 million low-income Americans annually.
  • Many of those on Medicaid are middle class individuals who spent all of their savings on care before becoming eligible.

 

We’re happy to help you walk through the process and coverage of your skilled facility needs. Our Executive Director and Social Services Director are happy to answer your questions. Feel free to call or drop in. Columbia Basin Care is located at 1015 Webber St in The Dalles, Oregon,  541.296.2156.