Jan 25

What’s the Difference between Medicare and Medicaid?

156400364It is unfortunate that Medicare and Medicaid have such similar sounding names.  While both are federally funded health care programs, the rules for qualification are different, and each program is designed to address very different health care issues.  This becomes particularly clear when families are faced with a health care crisis that begins with a trip to the emergency room, followed by the prolonged need for long-term care assistance with activities of daily living.

The situation is familiar to many of us.  Mom, dad or your spouse has a stroke or suffers a fall and breaks their hip, and is rushed to the emergency room.  For a number of weeks, and possibly for the rest of their life, he or she will not be able to perform daily activities on their own which are ordinarily taken for granted.  While many people assume that private health care insurance or Medicare will cover the cost of continuing care, for most patients this simply is not the case.

 Medicare Basics

Almost all people age 65 or older and are eligible for Medicare (even if you are not drawing Social Security benefits).  Whether you have a Medicare Advantage plan, or traditional Medicare with Part B (Medicare Supplemental) Insurance, and Part D (prescriptions), Medicare is designed to address acute care needs.  Routine health care is covered by Medicare, as well as procedures designed to improve a patient’s medical condition, such as cancer treatment and recovery, open heart surgery, dialysis, and physical therapy.  If the doctor can prescribe a medication, order therapy, perform surgery, or otherwise keep you on the road to recovery, Medicare generally covers the medical expense.

Medicare coverage is limited in long-term care situations. 

What Medicare does not cover, or only to a very limited extent, are chronic care needs; those health care costs associated with long-term care.  If a person needs assistance with Activities of Daily Living (ADLs), such as bathing, eating, dressing, ambulating (moving from one place to another), or medication management, Medicare covers the cost only in limited situations, and only for a limited time.

In order for Medicare to cover any of these expenses, a person must first be admitted to a hospital and stay at least three midnights.  These three midnights must also be for more than merely “observation”.  If this test is met, Medicare will cover up to 100 days of long-term care expenses, but only so long as the patient is showing progress or the care is necessary to maintain a level of personal health.  Regular evaluations are performed to see if this benchmark is being met.  Once it is determined that the patient is no longer making progress, or once the 100 days runs, Medicare will no longer pay for the cost of treatment.

 Medicaid and long-term care.

Medicaid, on the other hand, is designed to cover the cost of continued long-term care needs, but qualifying for benefits is not automatic.  Unlike Medicare, you must meet certain eligibility requirements in order to apply for and receive benefits.  Medicaid is available only to individuals who in general (1) need assistance in at least two Activities of Daily Living; (2) have a limited amount of income, including Social Security; and (3) are below the asset threshold set by the state.  If all three tests are met, and an Application for Benefits is submitted, the patient can receive financial assistance with the cost of long-term care, either at home, in an Assisted Living Facility, an Adult Family Home, or in an institutional setting such as a nursing home or skilled nursing facility.

If a patient is admitted to the hospital for a medical issue that results in the need for long-term care, do not expect Medicare to be available to cover the cost for any extended period of time.  Even most individuals’ private health care insurance does not pay for long-term care.  Do not wait until you are told by the hospital staff or discharge planner that Medicare will no longer cover the cost of the rehab or hospital stay; the time to start organizing a legal, financial and health care plan is right away.

Coordinating your legal, financial and health care planning can make the difference between maintaining your loved one’s quality of life and devastating the estate due to long-term care costs. Seek the advice of a qualified Elder Law attorney before the medical crisis becomes a financial crisis as well.

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