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Medicare, Medicaid, & Insurance 101

Posted on: Nov 08, 2017

Understanding your insurance options is important at any age, but takes on a special importance as we age. As we get closer to the age of 65, our insurance options drastically change. Before you get near retirement age, it’s crucial to consider your insurance options and budgetary constraints in order to make an informed decision.

Medicare 101

Millions of Americans have insurance coverage through the federal funded Medicare program. Most people are eligible to receive Medicare benefits after the age of 65 if they meet employment requirements imposed by the U.S. government. However, certain individuals with disabilities are able to receive Medicare coverage before the age of 65. Enrollment is determined after the Social Security Administration processes your application.

Medicare coverage is broken down into four parts:

Part A: Part A is a form of hospital insurance and anyone eligible for Medicare will receive this coverage. Part A of Medicare will also be used to pay for stays at a skilled nursing facility. Additional services covered under this part include hospice services, home healthcare services, surgeries, and medical tests. Some enrollees receive Medicare Part A without having to pay premiums while others are subject to annual premiums and co-payments.

Part B: Medicare Part B is also referred to as medical insurance coverage. Although all eligible individuals over the age of 65 are able to enroll in Part B, you are more likely to be subject to premiums when compared to Part A. Premium rates are often dictated by income. You may also need to meet an annual deductible before benefits kick in. Services covered under Medicare Part B include doctor’s visits, blood work, some home health services, and outpatient hospital testing.

Part C: Part C or Medicare Advantage will not come directly from the federal government. Private insurance companies who are paid directly by the federal government administer this type of plan. Coverage typically includes Part A and Part B services as well as prescription drug costs. The benefit of Part C is that the costs can sometimes be reduced than paying for all parts of Medicare required separately. However, you may have limitations on what providers you are allowed to use.

Part D: Prescription drug insurance providers approved by Medicare run Part D. This plan helps make medications more affordable to Medicare recipients. Medicare compiles a list of both brand name and generic drug covered under the plan. Each medication is separated into “tiers” with each tier having a different cost. Premiums for Part D are also evaluated based on income.

In most cases, patients will have Part A and Part B and then add on Part D to cover their prescription drug costs. Patients are permitted to visit any healthcare provider or medical facility that participates with Medicare. For Medicare Advantage, insurance providers will usually include Part A, Part B, and Part D.

To cover gaps left from Medicare, insurance providers often sell what is called Medigap coverage. This type of supplemental insurance will help pay for any medical costs not covered under your Medicare plan. Medigap’s enrollment period typically lasts for a six-month period after you start being covered under Medicare Part B. Medigap does require you to pay a monthly premium and will not cover prescription drug expenses.

Medicaid

While Medicare is run solely by the federal government, Medicaid is a joint partnership between the federal and state government. Medicaid’s purpose is to provide insurance coverage for the economically disadvantaged. Eligible parties may include low-income families with children, low-income seniors, and low-income individuals with disabilities. Eligibility can vary between family members. For instance, in some households, the children may have Medicaid coverage while the parents aren’t deemed eligible. The Federal Poverty Level typically defines income limits for Medicaid. Those with an increased medical need can also become Medicaid eligible if they spend their own money on health-related expenses. Besides financial requirements, you must also be a United States citizen to receive Medicaid. Medicaid eligibility is not affected by coverage through other health insurance companies. However, if you do have coverage through Medicare or another service provider, Medicaid will only pay for bills not covered by your other insurance plans. Medicaid may help pay premiums and co-payments associated with other health insurance policies. The federal government requires that each state give Medicaid participants options for choosing their healthcare providers. As long as a service is deemed “medically necessary,” it will be covered by Medicaid.

Medicaid will cover the following services:

  • Hospital stays
  • Skilled nursing facility stays
  • Doctor’s visits
  • Nurse practitioner care
  • Lab services
  • Birthing center services

Optional services that may be covered under Medicaid include:

  • Medications
  • Dental coverage
  • Rehabilitation services
  • Care management
  • Personal care

Always remember that older adults have more options than simply Medicare and Medicaid. Your former employer may offer retiree medical benefits that can keep you insured for years after your departure. You also have additional choices if you’re not eligible to receive Medicare or Medicaid coverage. You may be able to purchase insurance from the federal government’s Marketplace and save on your out-of-pocket costs.

 Assisted Living and Insurance Coverage

One of the most common misconceptions about Medicare is that you will not get any coverage when you need services provided by a nursing home. This is actually not the case. Medicare will pay for care within Medicare-certified skilled nursing facilities. Typical requirements for Medicare to cover your stay are you’ve had a minimum of a three-day hospital stay and your doctor determines you need nursing services. After your release from the hospital, Medicare will typically cover a maximum of 100 days in a certified nursing center. However, if you’re suffering from a serious illness or long-term disability, you may need supplemental insurance to help cover the costs of your stay. Medicare covered services must also be provided through a skilled nursing facility and not a continuing care community.

Medicaid may cover long-term services if you meet the eligibility requirements. Medicaid may help cover expenses associated with home healthcare services and nursing home stays. Medicaid coverage is dependent on whether you meet their income requirements. Medicaid nursing facility coverage will include room/board, nursing services, personal care, and any therapies required. Most states also have Medicaid waiver programs that help individuals stay within community care settings like an assisted living facility. To qualify, the individual must meet not only the income requirements, but also have his or her level of care required assessed.

The most important takeaway is senior living options are possible when you have coverage under Medicaid and Medicare. At the Pathways Skilled Nursing & Rehabilitation Center at the Philadelphia Protestant Home, we are certified by both Medicare and Medicaid. If you’re a current resident of our community, you will be able to stay on while receiving nursing care and rehabilitative services onsite. Amenities at the center include round-the-clock nursing care, recreation therapy programs, registered dietician consultations, psychiatric services, doctor’s offices, and much more. Our residents become part of our family and we make sure to work with each community member’s budget. If any of our members are unable to meet their monthly expenses, Philadelphia Protestant Home has a financial assistance program called the Benevolent Care Program. Contact us to learn more about our caring and compassionate community.

What Residents Say

"In my two years at PPh, I’ve grown to like it very much. At first, I felt like a stranger and then as I began to talk to people, we increasingly became good friends. A way to meet people is to join clubs. I’m now part of the PPh Auxiliary. I love helping with their flea markets because you never know what you can find. Recently, I’ve joined an evening quilting class. I love that I can continue to enjoy my life outside of PPh while experiencing the offers here.….especially the pool! Everything is just so convenient.

– Lucille Hite, Independent Living resident

What Families Say

"My mom is sooo happy at PPh, I can’t even describe it in strong enough words. She’s met so many new friends and these ladies do EVERYTHING together! She sees Dad every day in Pathways, but can have her life too. She’s gone to so many activities and I think I’ve already been to Scoops with her at least 15 times. She loves the dining room and Bistro too. My sister, Ilene, and I are so delighted that Mom is happy.......Wow, it feels like Mom’s been there about 2 years—but it’s only 2 months!! That’s how comfortable and natural it feels for her – and for all of us.

– Rhonda Frenkel, daughter of residents Jack & Bernice Segal