Health Insurance: Medicare and Medicaid

Medicare

care for the elderly

• 65 and older

• end-stage/permanent

• receive Social Security disability benefits for at least 24 months

Medigap

fills in the gaps that Medicare leaves behind

Medicaid

helps support those who need help with lower income

Medicare Parts

• Part A: hospital

• Part B: doctor

• Part C: care for managed care plans

• Part D: Prescription drugs

Part A

• benefit period: 90 days

• days 1-60, pay a deductible and medicare pays 100%

• days 61-90, pay a daily co-pay

• days 91+, additional 60 lifetime reserve days (don’t replenish)

skilled nursing facility

must have been admitted in the hospital for at least 3 days (pay the deductible) to be then moved to nursing home for 100 days of coverage

• Medicare pays for first 20 days

• days 21—100 are co-pay

• no more benefit after day 100

home health care

skilled medical care, 100% paid by Medicare

hospice care

covered by Medicare

Part A exclusions

• the first 3 pints of blood

• private duty nursing

• non medical services

• custodial services

Part B

optional coverage, premium must be paid

• outpatient medical

initial enrollment period

3 months before or after age 65

annual open enrollment period

January - March

• coverage does not start until July 1st

calendar year deductible

80/20 coinsurance after deductible

• after paying deductible, pay 20%

Part B exclusions

• routine physical exams

• outpatient prescription drugs

• physician charges over max amount

• private duty nursing

• care received outside of US

• expenses occurred from war or acts of war

Part C

advantage plans- must enroll in Parts A and B

• HMO

• POS

• PPO

Part D

prescription drug plan

• monthly premium

• purchased from a private insurance company

• premium charge is reduced by annual income level

• pay 25% of co-pay until reaching the gap

federal/state funded

Parts A and B

insurance company funded

Parts B and C

Medicare supplement policy

add on the federal program

• cover hospital co-pays days 61-90 (and lifetime days)

• adds additional 365 days of coverage

• covers part B coinsurance

• does not cover part A and B deductible

Medigap regulations

• must be given a buyers guide

• 30 day free look period

• guaranteed renewable policy

• guaranteed acceptance if bought within 6 months of Part B enrollment

Medicare select

coverage is offered through a restrictive provider selection

Medicaid

• funded by state

• must be a legal resident

• must be on welfare or supplemental security income

• age 65 or older

• blind