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Medicare and Medicaid

Healthcare in the United States is often out of reach for older adults and the working poor. Staying healthy without the finances to get basic healthcare is often challenging to people and disruptive to society. Since 1965, Medicare and Medicaid have helped vulnerable populations (older adults, the working poor, and people with disabilities) stay healthy.

Medicare and Medicaid are two government-funded and administered health insurance programs. President Lyndon B. Johnson signed them into law in 1965 with the Medicare and Medicaid Act. The Act is also known as the Social Security Amendments of 1965.

The Centers for Medicare & Medicaid Services, a division of the U.S. Department of Health and Human Services (HHS), administers the program. Although Congress has changed these programs over the past five decades, the fundamental purpose of these two health care programs has remained the same.

This FindLaw article overviews Medicare and Medicaid, including Medicaid expansion under the Affordable Care Act (ACA).

Medicare

Congress created Medicare to help older Americans and Americans with specific disabilities get care. Medicare is available for Americans 65 or older, based on their work history or spouse's work history. Medicare also covers people with end-stage renal disease (ESRD), Lou Gehrig's disease (ALS), and those who receive Social Security disability insurance income.

The Social Security contributions we make during our working years fund Medicare.

What Does Medicare Cover?

Medicare has multiple levels of coverage, with the most popular being Part A and Part B.

Medicare Part A

Medicare Part A covers the following types of care:

  • Inpatient hospital stays
  • Long-term care, like a skilled nursing facility or a nursing home
  • Hospice care
  • Home healthcare

After a deductible, Medicare covers nearly all other costs for the first 60 days of treatment. After those 60 days, Medicare patients must pay a coinsurance amount toward their hospital costs.

Part B

Medicare patients pay a monthly premium for Part B.

Part B covers basic medical and preventive services, including, but not limited to, the following:

  • Prescription drugs Medicare patients can't give to themselves
  • Durable medical equipment (DME)
  • Ambulance fees
  • Mental health care, including inpatient stays and intensive outpatient programs.
  • Diagnostic screenings (like diabetes or HIV)

Medicare Advantage

Medicare has two more parts: Part C, or Medicare Advantage, and Part D, Medicare's prescription drug coverage program.

Medicare Advantage refers to health plans offered by private health care companies. These plans often combine different Medicare "parts," such as Parts A, B, C, and Part D. Under Medicare Advantage plans, patients can select health care providers from within the plan's network. Some plans offer other health care services that regular Medicare does not provide, like the following:

  • Dental
  • Vision
  • Hearing

Private companies that offer Medicare Advantage health plans must follow the Medicare rules.

Medicaid

Although Medicaid is also a public health insurance program, it differs from Medicare in several key ways. First, the federal government does not administer Medicaid; each state administers Medicaid. Second, Medicaid eligibility extends to low-income Americans of any age in most states.

The federal government and states administer Medicaid through the state plan, which is an agreement each state has with the Centers for Medicare & Medicaid Services (CMS). The federal government provides the structure for Medicaid, but each state determines how it will administer Medicaid. Consider, for example, Medicaid expansion under the ACA. Before the ACA took effect, Medicaid eligibility was typically based on the following primary factors:

  • Income
  • Household size
  • Disability status
  • Family status

If people did not meet all the criteria, they couldn't get Medicaid benefits. Under the ACA, in states that expanded Medicaid, people can qualify for Medicaid based on their income alone. So, an unmarried person who fits the income criteria can qualify for this health assistance program.

Medicaid Coverage

Although health coverage will differ from state to state, in most states, Medicaid covers basic health care costs, like the following:

  • Doctor's visits
  • Preventive care (mammograms, vaccinations)
  • Hospital stays
  • Mental health care
  • Prescription drugs

Some state Medicaid programs cover other expenses, like eyeglasses and dental care. Since Medicaid benefits can vary between states, you should check with your state's department of health or department of human services for more information.

Children's Health Insurance Program (CHIP)

Many families earn too much to qualify for Medicaid but not enough to buy health insurance for their families. CHIP helps these families. CHIP is health insurance for uninsured children 21 and younger.

Pregnant Women

Pregnant women are an exception to Medicaid's eligibility requirements in some states. Typically, Medicaid beneficiaries cannot have an income that exceeds 133% of the Federal Poverty Level, as set forth by HHS. Pregnant women with household incomes higher than 133% of the Federal Poverty Level are often eligible for Medicaid, depending on their state's Medicaid rules.

Applying For Medicaid or Medicare

Anyone interested in Medicaid or Medicare can apply for either through their state's health insurance exchange or through the federal health insurance website. Open enrollment is the time frame within which most people can either apply for health insurance or renew their current plans. Open enrollment starts on Nov. 1 of each year and ends on Jan. 15 of the following year.

Special Enrollment

People who meet specific criteria can apply for health insurance during "Special Enrollment" periods. Such criteria include, but are not limited to, the following:

  • Losing health insurance
  • Moving
  • Loss of income
  • Change in family status (getting married, pregnancy)

People who meet any of these criteria may have up to 60 days after they meet the criteria to apply for new health insurance.

Medicare Special Enrollment

Medicare has its special enrollment periods based on specific life events. These life events include, but are not limited to, the following:

  • Moving
  • Loss of insurance coverage
  • An opportunity to get other types of coverage
  • Your plan's contract with Medicare changes
  • Special situations, including dual eligibility (eligible for Medicare and Medicaid)

Get Help

Public health insurance programs exist to ensure as many people as possible have access to health care. A family law attorney can help. Many attorneys have different fee arrangements to help you get the legal advice you need. Speak to an experienced family law attorney today.

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