Elder Law: M&Ms in Different Varieties

It is actually quite unfortunate that two distinct federal health programs share the same first 6 letters in their names.  It should come as no surprise that Medicaid and Medicare are often confused and misunderstood!  Let’s try to clear the fog and explore what these programs offer.

While both Medicaid and Medicare are federal health insurance programs that were created in 1965 and currently administered by the Centers for Medicare and Medicaid Services (CMS), they are really quite different.  The former is a means-tested, joint state and federal program that provides health care for individuals of all ages, and the latter is an entitlement program that provides health care for individuals over age 65 and those receiving Social Security disability for 24+ months.  To be financially eligible for Medicaid you must meet income criteria (as well as asset criteria for certain benefits), whereas eligibility for Medicare is based upon your work history or that of your spouse. 

One major area of confusion about these “M&Ms” encompasses long-term care coverage.  To put it plainly and simply:  Medicare does not cover long-term nursing home care.  However, there is a limited benefit for skilled nursing care, provided it was preceded by at least a 72-hour inpatient hospital stay.  Medicare will cover up to 100 medically-eligible days, with a co-pay of $164.50 for days 21-100 (though a supplemental health insurance may defray this cost).  If the individual has a “break” in skilled care for at least 60 days, this benefit will re-set and allow for another 100 days using the same criteria.

Although Medicaid does have a different medical test for its long-term care program (known in Vermont as “Choices for Care”), its main distinction from Medicare lies in requirement of  financial eligibility. When an individual meets the asset and income tests, he or she may receive nursing home level care at a facility or in the community for an unlimited period of time with monthly co-pays (called patient share) based upon income and some expenses. 

Medicare and Medicaid: same  candy coating, but different  on the inside.