Medicaid and Medicare are public health programs subsidized by the US government for the American people. The primary differences between the two programs are the way each is run, where its resources come from, and who they cover. Medicare is a health insurance that focuses on individuals 65 years of age and older and people with disabilities who are subject to social security. On the other hand, Medicaid is an assistance program that covers those individuals and families with low or no income.
There are people who may be eligible for both Medicaid and Medicare, but it depends on their personal circumstances. Since the implementation of Obamacare (Affordable Care Act), 26 states and the District of Columbia have expanded Medicaid, allowing more people to benefit from this program.
|Generalities||Medicaid is an American assistance program that covers the medical expenses of those individuals and families who report receiving low or no pay. Children are more likely to be chosen than adults in a family to benefit from the program.||Medicare is a health insurance program that primarily covers seniors (65 and older) and disabled individuals of any age who are eligible for social security. It also covers those people of any age who are in the terminal phase of kidney disease.|
|Requirements to be a candidate||There are strict income requirements directly related to the FPL (Federal Poverty Index). After the expansion of the program, 26 states cover those below 138% of the Federal Poverty Level (FPL).||Regardless of income, anyone can enroll in Medicaid as soon as they turn 65, as long as they can pay for it on their own or through their social security savings funds. People with severe disabilities or end-stage kidney disease are also candidates.|
|Service coverage||A child is more likely to be insured than an adult in all states. Medical care includes routine care and emergency actions, family planning, palliative care, programs to stop the abuse of some substances and cigarettes. Dental and vision care is limited.||Its coverage includes routine care and emergency actions, palliative care, family planning, programs to stop the abuse of some substances and cigarettes. Dental and vision care is limited.|
|cost||It varies depending on the state. It is usually a low amount, but this depends on how low the applicant’s income is.||Item A costs nothing for those who paid Medicare tax for 10 years or more (it also applies to spouses).Item B in 2014 cost $ 104.90 a month for almost everyone.Item D is for variable costs, almost all of which are around $ 30 per month.|
|Leadership||Run jointly by the federal government and the state government of each state that is part of the program. It is worth mentioning that it is universally governed by the Affordable Care Act and that the Supreme Court determined that states that so desired could leave the program.||Run entirely by the federal government.|
|Money||This program gets its funds from a variety of taxes, but most of it (about 57%) comes directly from the federal government. Sometimes hospitals are taxed at the state level; Along with Medicare, Medicaid receives 25% of the federal budget||Its funds come from payroll taxes (quoted with Medicare and social security), interest generated in trust investments, and the payment of Medicare premiums, along with Medicaid, Medicare receives 25% of the federal budget.|
|Satisfaction level||Relatively high||High|
|Covered population||All states, the District of Columbia, US territories (Puerto Rico, Guam, Samoa, etc.), Native American reservations. About 20% of the population has Medicaid. 40% of births are covered by it as well as half of HIV / AIDS patients nationwide.||All states, the District of Columbia, US territories, Native American reservations. About 15% of the US population is covered by|
Whether an entire family or an individual is eligible to be covered by the Medicaid program depends on very strict income requirements. Those with lower or no income, as well as those below the Federal Poverty Level or FPL, especially benefit. Because Medicaid costs are partially covered by the US federal government and state governments, the guidelines for this program vary from state to state. As for the federal Medicaid guidelines, these distinguish some groups as “mandatorily eligible” while others are “optionally eligible” and it is up to each state whether they are elected or not. In many cases, children take priority over adults in terms of eligibility. In fact,
As for Medicare, anyone 65 years of age or older can enroll in the program, even up to three months before reaching that age. This program does not approve or reject applications based on financial factors, but rather is based on age and whether the enrollee paid their Medicare Social Security premiums for any period during their lifetime (the minimum required is 30 fiscal quarters for full coverage ). However, there are two possible exceptions to these requirements. The first is for people under 65 years of age who have a recognized severe disability that qualifies for Social Security, can be approved by Medicare. The other is for anyone with end-stage kidney disease.
By law, both Medicare and Medicaid are exclusive to US citizens. However, there are reports of undocumented immigrants who have received Medicare services. Medicaid usually requires proof of legal residency, as well as that the beneficiary lives in the state where Medicaid is providing service.
Low-income Medicare beneficiaries may also qualify for Medicaid. This dual coverage can help someone who gets help from Medicare cover additional costs and out-of-pocket expenses. A significant minority of Medicare beneficiaries qualify or at some point become eligible to also be Medicaid beneficiaries.
One of the largest and most controversial reforms to the Affordable Care Act (Obamacare), was the expansion of Medicaid by relaxing some of the program’s financial requirements, making its rules more universal. Even more specifically speaking, anyone below 138% of the Federal Poverty Level could be eligible for Medicaid under this reform. This change would be something great in contrast to the previous requirements related to the income of the person, which varied according to each state.
This development was not well received by several state governments as well as by several politicians, and later, in 2012, a Supreme Court ruling allowed the states to reject the expansion of Medicaid. As of 2014, 26 states in addition to the District of Columbia (DC) have approved Medicaid expansion. Some others are still debating about it while 19 have chosen to reject it.
In general, Medicare tries to cover all possible health services under one of its several clauses: Medicare Part A, Medicare Part B, Medicare Part C (or Medicare Advantage) and Medicare Part D. However, Medicare only covers some services, which depend entirely on each state. Just as the federal government requires mandatory Medicaid coverage for some and optional for others, the same federal government allows the state optional coverage of some services.
|Service||Are you covered by Medicaid?||Is it covered by Medicare?|
|Abortion (in cases of rape, incest and risk to the life of the mother)||It depends on each state||Yes|
|Chiropractic services||It depends on each state||Yes, although limited|
|Dental health||It depends on each state, children are covered||Only in case of surgery|
|Periodic and preventive exams, diagnostic services and treatment||Yes||Yes|
|Vision care and glasses||It depends on each state||Yes, although limited|
|Family planning services||Yes||Yes|
|HIV screening tests||It depends on each state||Yes|
|Home health care||Yes||Yes|
|Palliative (terminal) care||It depends on each state||Yes|
|In-hospital care||Yes||Yes, full coverage for up to 60 days|
|Mental hospital care||It depends on each state||Yes, full coverage for up to 60 days|
|Analysis and x-rays||Yes||Yes|
|Medical supplies||Yes||If many|
|Medical Services for Native Americans||Yes||Yes|
|Nursing home service for the elderly||Yes||Yes, although limited|
|Other preventive or rehabilitative diagnoses||It depends on each state||Yes, although limited|
|Outpatient or outpatient care||It depends on each state||Yes|
|Physical and occupational therapy||It depends on each state||Yes, almost all|
|Controlled sale drugs||It depends on each state||Yes, although only in Medicare Part D|
|Prosthesis||It depends on each state||Yes|
|Programs to quit alcohol, cigarettes and drugs||Yes, although limited in many states||Yes, but very limited|
|Vaccines||It depends on each state, children are covered||Yes, although very limited|
Outpatient and regular medical care
Routine medical care, such as doctor visits and visits to specialist doctors, preventive care and diagnostic medical tests are covered by both Medicare and Medicaid.
Medicaid covers immunizations for all those under the age of 21 who are covered by Medicare or whose insurance does not cover them. Additionally, all Native American citizens, including those who are Alaska natives, are eligible candidates for full vaccination coverage up to age 18. As for Medicaid, insured adults are less likely to have full vaccination coverage provided by the program, although those kinds of specifications depend on each state.
Medicare Part B provides limited vaccination coverage. Specifically speaking, the program tends to cover mainly those preventive vaccines, such as pneumonia and influenza, as well as hepatitis B for those at risk of contracting it. Other vaccines that may be of interest to the patient, such as chickenpox, shingles, tetanus, and whooping cough are not included in Medicare Part B. Instead, they are likely to be found in Medicare Part D, which provides additional vaccines in addition to those already mentioned.
Restricted sale drugs
Although controlled-prescription drug coverage is optional for Medicare by federal law, no state currently lacks this coverage. However, the operation of this depends on each state; some charge higher fees for patent drugs as well as those that must be shipped by courier.
As mentioned above, Medicare Part D is in charge of covering drugs in Medicare. This is an additional plan to the one established by default, which includes subsections A (hospital coverage) and B (medical coverage). Medicare beneficiaries can access section D “buying” it through a private insurer. Beneficiaries also have the option to change plans to Medicare Advantage, or item C, which includes all of the above items.
Medicare offers fair and flexible coverage for mental health services. Sections A and B cover the user’s in-hospital and out-of-hospital care. On the other hand, subsection D covers psychiatric medications, offering them at significantly lower prices. On the other hand, psychiatric hospitalization is limited to 190 days, beyond this limit, the user must pay his own expenses.
While Medicaid in all states covers some mental health services, the cost of coverage varies due to the optional nature of these services. Psychological evaluations can be covered, however therapies and psychotherapies are hardly covered or have limitations. Medicaid programs are more focused on covering the care needed by those who suffer from conduct disorders (for example obsessive-compulsive disorder and post-traumatic stress disorder) and illicit substance abuse disorders (alcoholism, smoking, etc.). Medicaid programs in some states have some alternative plans that offer coverage for additional mental health services.
Emergency room and internment
Visits to emergency rooms and hospital admissions are covered by Part A of Medicare. Services received by doctors in hospitals are covered by subsection B. This coverage is usually considered expensive, since it includes accommodation in a semi-private room, food, medicines, nursing services and supplies, etc. Medicare absorbs all of these costs in full for up to 60 days plus an additional 30 days. After 90 days of confinement, Medicare stops covering the costs unless there is an extra bonus period.
The federal government requires that all Medicaid programs cover inpatient care and emergency room visits. It is worth mentioning that state governments have the right to charge a higher fee in the event of an emergency visit for a matter other than an emergency, after evaluation and treatment of this, within a hospital or a private clinic. This action was taken after noting that Medicaid users visited the emergency room more frequently for non-emergencies. However, one study suggests that Medicaid recipients do not actually visit the emergency room any more than other citizens.
In addition to the mandatory emergency coverage for Medicaid users, the US government has made it mandatory for Medicaid to cover emergencies for undocumented immigrants, as well as tourists and temporary residents.
Dental and visual health
As in many other situations, dental and vision health care is often more readily available to children than to adults. In addition, each state can decide if this care is available and covered. State programs are much more likely to cover dental emergencies than preventive care, such as dental cleanings and treatment of chipped or decayed teeth. Some states cover only one eye exam and one pair of glasses every three years for people 21 and older.
Similar to the way Medicaid works on dental care, Medicare tends to cover only dental emergencies. Medicaid does not usually cover preventive care or routine check-ups, the only exception is Medicare Advantage, as some of their plans cover some dental services. Hospitalizations related to dental conditions are covered by section A of Medicare, however the consultation or services provided by the dentist will be paid by the user. Regarding visual health, the guidelines are similar to those of Medicare, where the program does not cover non-emergencies or problems related to vision not related to diseases.
Family planning services are mandatorily covered by Medicaid. As for pregnancy and childbirth, these two are covered in full by both Medicaid and Medicare. Even in 15 states, Medicaid covers infertility treatment.
Medicaid covers, in all 32 states as well as in DC, abortion in case of rape, incest or risk to the life of the mother. Medicare covers abortions under the same circumstances. However, neither program covers voluntary abortions, as established in the Hyde Amendment.
When it comes to Medicaid, children (anyone under age 19) are the best-covered demographic. Furthermore, children in a family whose adults do not qualify for Medicaid can be covered by the Children’s Health Insurance Program (CHIP) . The federal government asks states to cover many child-focused health services through Medicaid and CHIP. Even most states have chosen to expand these programs by covering a wide variety of optional services.
On the other hand, Medicare does not usually cover children. However, there is the exception for cases where there are kidney problems that require dialysis or a kidney transplant.
Both programs often cover this type of hospice, but both do it in different ways. Medicare covers all “lodging” expenses but is only available to those patients whose doctor has ruled 6 months or less to live. On the other hand, Medicaid proposes this service as optional (for both adults and children) so some states may not cover it or have very restrictive limits. In addition, when a Medicaid user uses this service, they waive the other benefits of the program that could help to find a cure or a treatment for their illness. This decision is reversible at all times.
Health for Native Americans
Many Native American citizens as well as Alaska Natives are eligible for Medicaid, including CHIP and Medicare after age 65. An important feature of Medicare and Medicaid is cost reimbursement. Because within many reservations access to a healthcare provider affiliated with Medicaid or Medicare is difficult or non-existent, members of these communities are allowed to visit the nearest doctor and then reimburse them for the cost.
Under the Affordable Care Act, which expanded Medicaid services to Native American communities, Native Americans can access medical services any day of the year (unlike other U.S. citizens) and a large number of out-of-pocket expenses are eliminated.
Programs to quit drugs, alcohol and cigarettes
Sections A and B of Medicare cover intra-hospital and extra-hospital care for substance abuse programs, respectively. Except for methadone treatment, subsection D often covers, if necessary, medications used to help fight addictions. Smoking cessation programs are also covered, but only include up to eight therapy sessions per year.
One of the many reasons for the expansion of Medicaid under the Affordable Care Act was to include and expand the program against cigarette and illicit substance abuse, although these programs are optional by law. However, even with expansion, there are limitations, especially in some states. These limitations especially refer to the time during which the user is allowed to participate in these programs without paying anything or paying very little.
In the past, when states like Massachusetts expanded their access to these programs via Medicaid, there were clearly positive effects. Among these, the hospital incidence of heart attacks decreased by up to 50% among smoking users. It is worth mentioning that the smoking cessation program is mandatory and is covered in pregnant women.
Costs for users
For many individuals and families, neither Medicare nor Medicaid is completely free. In some ways these programs operate as government-dependent insurers that charge small fees. However, individual experiences, costs, and cases vary from person to person. Most importantly, costs and coverage change annually.
Enrollment costs for Medicaid vary by state. Some states require users to pay small co-insurance fees, pay out-of-pocket or some other minor expenses, and even pay deductibles. The only exception to this are cases in which the federal government prohibited the collection of fees, such as family planning services, pregnant women, and all preventive services for children. No service should be denied even to those who fail in their payments, nor will they be charged immediately, but at some point the state could try to get their money back.
Almost all Medicare beneficiaries, who are not also helped by Medicaid or any other welfare program, pay a monthly fee, just like paying for private insurance. For section A of Medicare, during 2014 users were charged a fee according to their employment history (or that of their spouse). All those who personally (or their spouse) have personally paid their Medicare fees or taxes for at least 10 years, are not charged item A. Likewise, there are special fees for those who have not paid their fees for at least 10 years .
Regarding item B, there is a fixed monthly fee of $ 104.90 USD for those with an annual income of less than $ 85,000 or $ 170,000 if it is a couple. Those who have incomes higher than these figures, pay higher fees for this subsection.
Item D has an additional cost from A and B. Also, since this type of coverage is usually provided by private insurers, the cost varies. However, the average national monthly fee during 2014 was about $ 33 USD. A person with regular drug expenses should be aware that item D has an annual cap on coverage. This aspect is intended to be phased out thanks to the Affordable Care Act.
Medicare Advantage plans, which are often HMOs (Health Maintenance Organization) or PPOs (Participating Provider Option), tend to charge the Part B fee, plus about $ 40 for Medicare Advantage and between $ 30 and $ 70 USD for medical coverage, depending on the type of plan.
In some states, Medicaid receipts are deductible, especially for those who qualify to receive it but are not within acceptable economic levels. For example, in the state of Wisconsin those who earn a minimum of $ 100 USD per month have $ 600 USD in deductibles per six-month deductible period. Medicaid deductible guidelines vary a lot from state to state, so checking with local authorities is highly recommended.
Part A of Medicare has an annual deductible of $ 147 USD, on the other hand that of part B is $ 1,216 USD for each period.
Depending on the location, sometimes finding a specialist doctor who accepts Medicaid or Medicare can be difficult. In extreme cases, such as when the closest doctor who accepts either of these two programs is far enough away, users of both Medicare and Medicaid are allowed to visit any doctor. The doctor will be reimbursed for his services. The downside is that this process can be slow and requires a lot of paperwork.
The inefficiency of the process has had negative consequences. One of them is that many healthcare providers choose not to see patients enrolled in these programs. The Affordable Care Act has tried to fight this by committing to doctors to reimburse a higher fee, but it is a matter of time to know if this offer will work.
Management and financing
As for Medicaid, this program is managed, in addition to having been founded, by the federal government of the United States and each of its state governments. Still, the federal government has the final say on those mandatory categories. In addition, it often covers the highest percentage of costs (around 57%) and reimburses states for many of their medical costs generated by Medicaid as well as those generated by the new healthcare reform. In fact, there are a wide variety of taxes that help pay for this program.
Payroll taxes (nominal discounts for social security or Medicare), as well as interest generated by investments on trust funds, as well as fees, keep Medicare going.
When the numbers are put together, Medicare and Medicaid received about 25% of 2013 federal spending, followed by spending on social security (23%) and national defense (18%).
Who is covered?
Medicaid enrollment has steadily increased since the program began in 1965. However, it is growing even faster in those states that agreed to expand the program thanks to the Affordable Care Act. It is estimated that 71 million people, nearly 22% of the US population, will be insured with Medicaid by 2015. Many of those enrolled in Medicaid are over the age of 65 and therefore also qualify for Medicare.
Medicaid is an important service for the population infected with HIV / AIDS, covering almost 50% of the individuals living with this disease in the United States. In addition, it is estimated to cover 28 million children plus another 5.7 who benefit from CHIP. Finally, 40% of births in the United States are partially or completely covered by Medicaid.
There are gaps in the coverage of these two services, which contribute significantly to the number of uninsured people in the United States. A large number of these people are self-employed contractors. As for Medicaid, these gaps are caused mostly by some states, which limit eligibility for all but the extremely poor (those below 50% of the Federal Poverty Level). Also, with the resounding refusal of several other states to expand Medicaid, the problem is likely to continue.
Similar problems exist in Medicare, although to a lesser extent. The most common gap for beneficiaries of this program is the Medicare Part D gap. After a beneficiary reaches the annual cap on drug purchases, he or she must cover the expense. For some, this represents a huge expense, pushing many older users to stop taking essential medications or to seek help from Medicaid. Many users, knowing this limit, decide to insure themselves through Medigap, an insurance that covers this gap.
Both programs are very popular in the United States. Its users tend to have rather positive reviews regarding both, even more so when comparing them with a private insurer. It is for this reason that budget cuts seem impossible, as many citizens oppose the measure.
Despite the popularity of Medicaid, the expansion of the program does not have a universal level of approval. This resistance to expansion is not unusual among Americans when it comes to changes in social programs related to health. Historically, it can be remembered that Medicare was extremely unpopular when it was introduced, the same for its subsection D. Now it is a matter of time, to know what will happen with respect to the expansion of Medicaid.