Medicare vs. Medicaid: A Quick Recap and Reference Guide
Who qualifies and how do the programs differ? Keep reading for a quick review.
THE VBP Blog
April 6, 2023 – When reading through our blogs, you read a lot about Medicare, Medicare Advantage, and Medicaid. But do you sometimes need a refresher on what those programs are and who is eligible? If so, you are in luck! For this week’s blog, we are throwing it back to the basics with a quick guide on the Medicare and Medicaid programs. Feel free to bookmark this webpage and use it as a resource if you ever need a quick recap!
What is Medicare?
Medicare is health insurance that people over 65 and certain people under 65 with specific disabilities or conditions can obtain through the federal government. The Centers for Medicare & Medicaid Services (CMS) runs the Medicare program and establishes certain standards for costs and coverage. No matter what state a person lives in, their Medicare coverage will be the same. Individuals with Medicare pay part of the cost of their services and rugs through monthly premiums, deductibles, and coinsurance.
It’s important to remember that Medicare offers health insurance a large group of people including low-income families, pregnant women, people of all ages with disabilities, and those who need long-term care.
What is Medicaid?
Medicaid is a joint state and federal program that assists children, adults, pregnant women, people with disabilities, and seniors with limited income and resources by covering medical costs. The federal government establishes certain rules that all state programs must follow, but states run their own programs. This means that eligibility requirements and benefits vary from state to state. You can click here to access links to each individual state Medicaid program, including eligibility and enrollment.
There can be many nuances to Medicaid, but it covers 1 in 5 Americans including many with complex needs. This includes the poorest, most vulnerable population acting as a high-risk pool for private insurance companies. Children account for more than 43% of all Medicaid enrollees, and the elderly and people with disabilities account for 25% of enrollees.
A unique aspect of Medicaid is that over two-thirds of Medicaid beneficiaries are enrolled in a private managed care plan. Managed care plans are responsible for ensuring access to Medicaid services and providers. This is an area where value-based payments is on the ride to increase quality of care and control costs. Click here for a link to the Medicaid Managed Care website, which includes the Final Rule, Enrollment Reports, and other helpful resources!
What is Medicare Advantage?
While Medicare seems straight forward, it can get a bit confusing when you start talking about the different Parts. It’s easy to get these mixed up, so we’re here to provide a quick recap for you on Medicare Advantage and how it differs from traditional Medicare!
Traditional Medicare includes Part A and Part B, these give you both inpatient and outpatient health coverage.
edicare Part A: Hospital Insurance that covers hospital stays up to 60 days, nursing services, intensive care services, lab tests and x-rays while at the hospital, surgery and recovery costs, part-time home nursing care, and rehabilitation and therapy services among others.
Medicare Part B: Medical Insurance that covers doctor visits, vaccinations, health screenings and medical tests, medical supplies, ambulance services, and preventative health care programs, among other items.
Medicare Advantage is also called Medicare Part C. It includes everything under Part A and Part B, as well as additional coverage for dental, hearing vision, and more. Medicare Advantage plans can replace Original Medicare plans depending on the plan and coverage that you choose.
It is important to keep in mind that the big difference between Original Medicare and Medicare Advantage is coverage. With Original Medicare, you can go to any doctor or hospital in the country that takes Medicare. Under Medicare Advantage plans, in most cases, you can only see providers that are in the plan’s network and service area. You may also need a referral to see a specialist, which isn’t required in most cases under Original Medicare.
Cost is also something to consider when comparing original Medicare and Medicare Advantage plans. Some Medicare Advantage plans have $0 premiums, and on average, monthly premiums are lower than what consumers may pay for Original Medicare. However, the cost of Medicare Advantage plans varies depending on location.
Even if there is a cost difference, the benefits and all-encompassing coverage that Medicare Advantage plans offers is often worth it. As people age, healthcare protection becomes even more important. Increased coverage offers mind because you won’t get surprised by medical bills in the event of a sudden injury or illness. Medicare Advantage plans can also offer more value, depending on location and what coverage is selected.
Advocates Perspective
Healthcare coverage is important to ensure that people are able to receive the healthcare services they need to achieve their optimal health outcome. While many are covered through private insurance plans, both federal and state governments offer programs that provide health insurance coverage to individuals that meet certain criteria. It is important to note that recently, there has been a shift towards value-based payment for these plans through managed care. This is a promising step towards improving healthcare be rewarding providers for outcomes achieved, rather than the number of services provided. Subscribe to our blog to stay in the loop on these advances and be sure to bookmark this blog in case you are in need of a quick Medicare and Medicaid guide in the future!
Onward!
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About the Author
Fady Sahhar brings over 30 years of senior management experience working with major multinational companies including Sara Lee, Mobil Oil, Tenneco Packaging, Pactiv, Progressive Insurance, Transitions Optical, PPG Industries and Essilor (France).
His corporate responsibilities included new product development, strategic planning, marketing management, and global sales. He has developed a number of global communications networks, launched products in over 45 countries, and managed a number of branded patented products.
About the Co-Author
Mandy Sahhar provides experience in digital marketing, event management, and business development. Her background has allowed her to get in on the ground floor of marketing efforts including website design, content marketing, and trade show planning. Through her modern approach, she focuses on bringing businesses into the new digital age of marketing through unique approaches and focused content creation. With a passion for communications, she can bring a fresh perspective to an ever-changing industry. Mandy has an MBA with a marketing concentration from Canisius College.