Navigating the Maze of Medical Terminology: Part 3- Medicare vs. Medicaid

frustrationBoth Medicare and Medicaid are government funded programs. You may have already known that but you may be confused as to the difference in benefits.

Medicare is for those who are 65 years of age or older who have paid into the system or who have a disability. It has a part A and a part B. Part A is for in-patient services such as the hospital. Home care benefits are also paid through part A as they consider it an extension of the hospital benefit since most home care Medicare patients are admitted after a hospital discharge.

Part B is for outpatient benefits such as doctor services or outpatient therapy. This column is not meant to get into the complexities of deductibles, premiums, benefit periods, certification periods or the myriad of other subjects in the land of Medicare. You can find all those answers here at the Medicare site.

Medicaid is a healthcare program for people with a low-income. There are a variety of programs just for the elderly, pregnant women, people with developmental disabilities, and children only. Depending on the situation, a person may qualify for a Medicaid program. For Indiana, you can check basic eligibility requirements here.

Medicare will cover skilled services if the patient is home bound, needs only intermittent skilled services, and is under the care of a physician who oversees the home care plan of care. Medicare does not cover custodial services (i.e.- you want to bring a parent home who has dementia and you think Medicare will pay for someone to stay with them while you are away.)

Traditional Medicaid will cover skilled services after hospitalization for up to thirty days. Any skilled serves needed after that thirty-day period will need prior authorization from the Medicaid office. Medicaid may also pay for custodial services if there is documentation of need and lack of caregiver.

The Medicaid Waiver program was designed to offer an alternative to institutional placement when elderly and disabled patients wanted to stay at home. Don’t get too excited though. While the program will provide companion care, transportation, and aide services, the reimbursement rates are so low and regulations so vast that there are very few agencies who accept waiver services anymore. This has caused a large waiting list for eligibility and also finding an agency to provide services.

A patient may be eligible for both Medicare and Medicaid. They are both regulated by the US Government at the Centers for Medicare and Medicaid Services better known as CMS. In Indiana they are both also overseen by the Indiana State Department of Health. Home Health agencies may be certified to provide both Medicare and Medicaid services or just one. If you are looking for a home care agency, it would be better to choose one who has both certifications in case you ever need services from both Medicare and Medicaid so services can be coordinated more efficiently.

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