Medicare vs. Medicaid: What’s The Difference?

Jul 25, 2023

There are two terms that are often mentioned when it comes to healthcare in the United States – Medicare and Medicaid. In order to make informed healthcare choices, it is crucial that individuals understand the differences between these two government programs, including coverage options, eligibility requirements, and how an elder care attorney can help.

What Is Medicare?

Medicare is a federal health insurance program primarily designed for individuals aged 65 and older. However, it also covers certain younger individuals with disabilities and those with end-stage renal disease. Medicare is divided into different parts, each providing specific types of coverage.

Eligibility Requirements For Medicare 

To be eligible for Medicare, individuals must meet one of the following criteria:

  • Being 65 years or older and either a U.S. citizen or a legal permanent resident who has lived in the United States for at least five consecutive years.
  • Being under 65 but receiving Social Security Disability Insurance (SSDI) for at least 24 months.
  • Having end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS), regardless of age.

Medicare Part A: Hospital Insurance

Medicare Part A, also known as Hospital Insurance, covers inpatient hospital care, skilled nursing facility care, hospice care, and some home healthcare services. Individuals who have paid Medicare taxes while working for a certain number of years are typically eligible for premium-free Medicare Part A. However, others may need to pay a monthly premium.

Medicare Part B: Medical Insurance

Medicare Part B, or Medical Insurance, covers services from doctors and other healthcare providers, outpatient care, durable medical equipment, and some preventive services. Part B requires individuals to pay a monthly premium. It is important to note that while Part A is largely premium-free for most eligible individuals, Part B always requires a monthly premium payment.

What Services Are Not Covered By Medicare?

While Medicare offers substantial coverage for various healthcare services, there are certain things that are not covered under the program. Understanding what is not covered under Medicare is essential for beneficiaries to plan for any out-of-pocket expenses they may incur. Some of the services not covered by Medicare are:

  • Long-term care services including the assistance with activities of daily living, such as bathing, dressing, and eating, that are often required by individuals who have chronic illnesses or disabilities. 
  • Costs associated with nursing home care or home health aides for extended periods of time. Therefore, individuals who require long-term care services may need to explore other options, such as purchasing long-term care insurance or relying on Medicaid. 
  • Dental care-routine dental services, including cleanings, fillings, and extractions, are generally not covered by Medicare. 
  • Vision care including eye exams, eyeglasses, and contact lenses. 
  • Prescription drugs in their original form. Beneficiaries have the option to enroll in a separate Part D prescription drug plan offered by private insurance companies and typically require payment of a monthly premium in addition to copayments or coinsurance for each prescription.

Medicare provides comprehensive health insurance coverage for many healthcare services, there are certain things that are not covered under the program. Understanding the limitations of Medicare can help individuals make informed decisions about their healthcare and financial needs.

What Is Medicaid?

Medicaid, on the other hand, is a joint federal and state program that provides health coverage for individuals with low income or limited resources. Unlike Medicare, Medicaid is not solely based on age or disability. Each state has its own eligibility criteria and determines the specific benefits offered under Medicaid. Therefore, it is important to check with your state’s Medicaid office to understand the requirements in your area. The eligibility requirements for Medicaid in Texas vary depending on the specific category of eligibility. 

For most Medicaid programs in Texas, the income eligibility limit is based on a percentage of the Federal Poverty Level (FPL).

Income limits vary depending on factors such as family size, age, and disability status. Pregnant women, children, parents/caretaker relatives, and individuals aged 19 to 64 may have different income thresholds. To be eligible in 2023 a two-person household has to make less than $1,526 per month/$18,310 per year,  and a family of four no more than  $2,313 per month/$27,750  per year. These are general guidelines, but your situation may vary depending on the size of your family.

Residency and citizenship: To be eligible for Texas Medicaid, individuals must be U.S. citizens or qualified non-citizens residing in Texas. Proof of identity, residency, and citizenship or immigration status is required.

It’s important to note that Medicaid eligibility is complex, and there are different programs within the Medicaid system. The eligibility requirements and application processes can change, so it’s essential to verify the most up-to-date information through the Texas Health and Human Services Commission (HHSC). To apply for Medicaid in Texas, you can use the online portal YourTexasBenefits or contact your local HHSC office for assistance.

Can You Have Both Medicare And Medicaid?

In certain cases, individuals can be eligible for both Medicare and Medicaid, often referred to as “dual eligibility.” When someone has dual eligibility, Medicare is the primary payer for healthcare services, and Medicaid can help cover some of the costs that Medicare does not pay for. Dual eligibility can provide individuals with more comprehensive coverage, including benefits such as prescription drugs, long-term care, and other services not fully covered by Medicare alone.

How An Elder Care Lawyer Can Help With Medicare And Medicaid

  1. Eligibility and Planning: Medicare and Medicaid have specific eligibility requirements, and an elder law attorney can help you understand these requirements and assess your eligibility. They can guide you through the application process, ensuring you meet all the necessary criteria and increase your chances of approval.your chances of approval.
  2. Asset Protection and Spend-down Strategies: Medicaid has strict asset and income limits to qualify for long-term care coverage. An elder care lawyer can advise you on various legal strategies to protect your assets and reduce your reported income to meet these limits. This may involve creating trusts, transferring assets, or utilizing other legal tools.
  3. Long-Term Care Planning: If you or your loved one needs long-term care, an elder care lawyer can assist in developing a comprehensive plan. This may involve exploring options such as long-term care insurance, setting up a trust to fund care expenses, or coordinating Medicaid benefits to cover nursing home or in-home care costs.
  4. Medicare Appeals and Coverage Issues: If you encounter difficulties with Medicare, such as denied claims or coverage disputes, an attorney can help navigate the appeals process. They can review your case, gather relevant evidence, and represent your interests to ensure you receive the Medicare benefits you are entitled to.

Having a knowledgeable attorney by your side can provide peace of mind and ensure that your health care needs are addressed and that you receive the appropriate benefits and legal protections. It is recommended to consult with an experienced estate plan or elder care lawyer who is qualified in these areas to create a tailored plan based on your specific circumstances.

Call Michelle E. Murphy To Help You With Your Healthcare Needs

For over 20 years, The Law Offices of Michelle E. Murphy has been helping seniors and their families with Medicare and Medicaid. Whether you’re looking for legal healthcare advice or tackling immediate pressing legal healthcare concerns, Michelle E. Murphy will give you the personalized attention you deserve. Along with her unmatched experience and knowledge of elder law, her compassion for helping seniors and caregivers navigate the complexities of elder care issues make her the perfect choice to assist you in your journey. Call today to schedule a free consultation and learn more!