APPENDIX E
MEDICARE & MEDICAID
Medicare
The purpose of this section is to provide a general overview of the Medicare program. For more specific information go to www.medicare.gov or contact the Social Security Administration. Medicare is a health insurance program that is administered by the federal government. This program is financed through taxes paid by employees and employers. The primary purpose of the program is to provide a health care safety net for individuals retired from the workforce. There are three groups that are eligible for Medicare: individuals ages 65 and older who have paid into the system, certain individuals under age 65 who have disabilities and individuals with End-State Renal Disease.
Medicare has two parts, which are briefly described below:
Medicare Part A (Hospital Insurance) is available without cost to individuals who paid Medicare taxes and certain other individuals. Part A covers (certain copays and other costs may apply):
- Hospitalization for illness or injury
- Inpatient psychiatric care
- Care in a skilled nursing facility
- Home health care for individuals with an illness or injury and meeting certain conditions. This benefit provides part time limited skilled nursing care and other therapeutic services.
- Hospice care for individuals meeting certain conditions (must be terminal within 6 months as determined by a physician)
- Blood given at a hospital or skilled nursing facility
Medicare Part B (Medical Insurance) is available for a monthly premium of $45.50 to individuals who choose to enroll and who are eligible to receive Medicare Part A. The following services are covered under Part B (copays and other costs may apply):
- Medical and other services such as non-routine doctor visits, medical equipment, outpatient therapies
- Clincal lab services
- Home health care for individuals with an illness or injury and meeting certain conditions This benefit provides part time limited skilled nursing care and other therapeutic services.
- Outpatient hospital services for diagnosis and treatment of injury
- Blood
- Preventative Services including bone mass measurement, colorectal cancer screening, diabetes monitoring, annual mammogram screening, pap smears and pelvic exams, prostate cancer screening and vaccinations
Today, there are three types of Medicare plans: original, managed care and private fee for service - only original is available in all parts of the country (HCFA 2000 Medicare Basics).
In addition to these two plans, Medicare also offers supplemental insurance or Medigap policies. There are ten different plans that are intended to cover out of pocket costs not covered under other Medicare policies. Medigap insurance can be purchased from private insurance agencies and is available to individuals who have both Parts A and B. These policies are not necessary for individuals who receive Medicaid, are members of a Medicare HMO or are covered under an employee group health insurance plan (Texas Dept. of Insurance 2000).
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Medicaid
The purpose of this section is to provide a general overview of the Medicaid program. Medicaid is a means tested health insurance program for low-income individuals who meet certain eligibility guidelines. At the federal level, Medicaid is administered by the Social Security Administration and by the Department of Human Services at the state level. States have a wide range of flexibility in how they administer their programs, who receives services, what services are available and how much is paid per service. It is possible for older adults to receive both Medicare and Medicaid.
Medicaid covers a variety of services and costs such as medical expenses, nursing home care and out of pocket expenses such as Medicare premiums. Additionally, Texas has in place several Medicaid waivers that allow the state to use resources for home and community based care as an alternative to institutional care. The Community Based Alternatives program provides the following services:
- Adaptive aids and medical supplies (limit of $10,000 per year)
- Adult foster care
- Assisted living/residential care services
- Emergency response services
- Nursing services
- Minor home modifications (Limit of $7,500)
- Occupational therapy
- Personal assistance services
- Physical therapy
- Respite care (30 days per year)
- Speech pathology services
- Home delivered meals
To be eligible for these services, clients must:
- Be age 21 or older
- Be eligible for Medicaid (income less than $1500/month with resources of less than $2,000 for an individual; SSI or MAO protected status)
- Meet two or more criteria for nursing home risk
- Reside in own home, with family, in assisted living or residential care facility or a DHS Adult Foster Care home
Currently, the demand for services provided through the Medicaid waiver program exceeds the number of slots. Texas is approved to serve more individuals but has not allocated the resources necessary to do so (TDHS 2000 Frequently Asked; Wiener; TDHS May 2000).
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