Medicare Vs Medicaid: How Medicaid Works
Medicaid is a need-based joint federal and state insurance program that covers low-income individuals and families. That said, Medicaid coverage can vary significantly from state to state. Thats because the federal government covers up to 50% of each states Medicaid program costs. This means all remaining Medicaid program costs must be paid for at the state level.
Unlike Medicare, Medicaid isnt available to everyone and it has very strict eligibility requirements. To qualify for Medicaid coverage, you must either already be receiving SSI benefits or fit within a mandatory eligibility group. If your financial resources arent limited enough to qualify for SSI, you may still qualify for state-based Medicaid assistance programs. For more information about the updated Medicaid eligibility requirements under the Affordable Care Act , visit the Medicaid.gov website.
While each states coverage varies , the federal government requires that there is coverage for the following services as long as theyre deemed medically necessary.
- X-rays
- Preventive care for children under 21
Do You Automatically Get Medicare With Social Security
Medicare and Social Security are two benefits programs managed by the United States government. Medicare currently has over 61 million beneficiaries.
Both federal initiatives are linked, meaning that many individuals receiving Social Security payments may automatically receive Medicare benefits once they qualify for Medicare based on age or disability.
In this article we review how people can receive Medicare health insurance coverage alongside their Social Security benefits.
You May Qualify For Legal Assistance
Figuring out which healthcare plan will cover you can be confusing especially if you havent yet filed your disability claim. A local disability advocate can walk you through Medicare vs Medicaid coverage available in your state. Its almost impossible to tell whether youre eligible for healthcare assistance programs without first knowing your individual circumstances and location.
Ready to see if you may qualify? Click the button below to start your free online benefits evaluation now!
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What Do The Different Medicare Components Cover
Medicare has three different components, and every recipient isnt necessarily entitled to use all of them:
- Hospital: Medicare Part A provides hospitalization coverage as well as paying some hospice, nursing home and home health care costs.
- Medical: Medicare Part B works like most private insurance policies and covers doctors visits, lab work, and visits to the emergency room.
- Prescription Drugs: Medicare Part D helps cover prescribed medication costs. Medicare Part A and B participants are eligible for Part D .
Definition Of A Disability
The Social Security Administration has a very strict definition of disability. To be considered disabled:
- You must be unable to do any substantial work because of your medical condition
- AND your medical condition must have lasted or be expected to last at least one year, or be expected to result in your death
According to the law, your SSDI payments cannot start until you have been disabled for at least five full months, although a recent law change expedited this process for people with ALS. Your payment will usually start with your sixth month of disability.
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Can I Get Medicare Or Medicaid While Receiving Social Security Disability Payments
After being approved for disability benefits, whether you receive Medicaid or Medicare will depend on whether youre also getting SSI or SSDI benefits. Those who qualify for Supplemental Security Income are eligible for Medicaid, while those who receive Social Security Disability Insurance qualify for Medicare. However, SSD recipients wont receive medical benefits from Medicare until two years after their application has been approved. Those who receive SSI dont have to wait before receiving Medicaid. Lets take a closer look at SSI, SSDI, and Medicare/Medicaid.
Most People Who Are Approved For Disability Benefits Through The Social Security Administration Get Medicare Or Medicaid Eventually
By Bethany K. Laurence, Attorney
Generally, if you are approved for Social Security disabilityinsurance benefits, you will receive Medicare, and if you are approvedfor Supplemental Security Income , you will receive Medicaid. However, thisisn’t true in all states. Medicaid is operated by the states,and the states are allowed to set eligibility criteria that are different thanSSI’s criteria. As a result, whether getting approved for SSI gets you Medicaiddepends on your state, as we’ll discuss below.
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Can I Have Both At The Same Time
If you qualify for both Medicare and Medicaid, you can have them both simultaneously. When you have both it means that you are unlikely to have any out-of-pocket medical expenses. Around 20 percent of Medicare beneficiaries are also eligible for Medicaid. They are called dual-eligibleDual-eligible beneficiaries are those who receive both Medicare and Medicaid benefits. It includes beneficiaries enrolled in Medicare Part A and/or Part B while receiving full Medicaid and/or financial assistance through a Medicare Savings Program….. You would need to apply for each one separately to determine if you can qualify for both.
Dual-eligibles are categorized based on whether they receive full or partial Medicaid benefits. Full benefit dual-eligibles receive comprehensive Medicaid coverage, while partial benefit dual-eligibles receive help with their Medicare premiums and cost-sharing through one of four Medicare Savings Programs.
Medicare And Ssdi Benefits
Disabled individuals receiving SSDI benefits qualify for Medicare coverage, no matter their age. This coverage becomes effective two years after the individuals alleged onset date of disability. This date of disability is the date the individual and Social Security Administration agrees they became disabled. For many of our clients, the waiting period is minimal since their alleged date of disability is in the past and since the process of applying for disability can be lengthy. Once they receive and the SSA processes their approval, many claimants begin receiving their monthly payment and insurance benefits immediately.
In closing, its not an overstatement to say that having access to health insurance AND a monthly stipend is life-changing for disabled people. If you or someone you know is struggling with disability and is unable to return to work, wed be happy to provide you with a free consultation on your claim. We serve claimants throughout North Carolina.
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Medicare With Als Or Esrd
There are two exceptions to the 2-year waiting period. If you have amyotrophic lateral sclerosis , also known as Lou Gehrigs Disease, youll be enrolled in coverage in the first month you receive SSDI.
If you have end stage renal disease , your Medicare coverage normally begins after youve received 3 months of dialysis treatment.
Unitedhealthcare Senior Care Options Plan
UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.
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Can You Get Social Security And Not Sign Up For Medicare
Yes, many people receive Social Security without signing up for Medicare.
Most people arent eligible for Medicare until they turn 65. As you can start collecting Social Security retirement benefits at 62, individuals may have Social Security without Medicare for several years.
Most people enroll in Part B once they turn 65, but you may decide to delay enrolling in Part B if you or your spouse has health insurance through an employer. Be sure to learn more about how Medicare enrollment works in your specific case, though. If you delay enrollment in Medicare Part B when youre first eligible and you dont have other creditable coverage, you could face late enrollment penalties for the rest of the time that you have Part B once you sign up.
As most people dont pay a premium for Part A, theres no reason to cancel the coverage, even if you dont think you need it. You are free to decline other Medicare plans, such as Parts B and D, though again you should make sure you wont cause yourself to go without coverage or have to pay late enrollment penalties in the future.
When Will My Medicare Begin
In most situations you can receive Medicare disability benefits once you receive Social Security disability income benefits for 24 months. Medicare disability coverage begins the 25th month. The 24-month period begins the month you are entitled to receive Social Security disability benefits. In some cases this could be earlier than the month you receive your first disability benefit check. A person who has ALS and is under age 65 can get Medicare benefits the first month he or she is entitled to SSDI or railroad retirement disability benefits. If you have ESRD , you are eligible for Medicare benefits:
- the first month you start to administer a regular course of dialysis treatment after receiving selfcare training, or
- the fourth month you receive treatment at a dialysis center , or
- the month the transplant is done or the month of hospitalization as an inpatient up to two months before the transplant, if pre-transplant testing has begun.
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What If My Income Is Too High For Ssi
Some people worry that their income will disqualify them for SSI and Medicaid. Usually, you will continue to qualify for Medicaid if the following remains true:
- Youre blind or disabled and
- Except for your income, you meet SSI eligibility rules and
- You qualify for at least one month of SSI payment before meeting SSAs Section 1619 and
- You met Medicaid eligibility in the month before qualifying for Section 1619 and
- To be able to work, you need Medicaid
The last rule is that your work income cant replace the value of your assistance. This includes Medicaid or SSI cash benefits. Your earning cant cause the loss of publicly funded personal care related to your income.
Even if your earnings exceed the threshold, you may still qualify for help. For example, you may get Medicaid for special work or medical expenses.
Always notify the funding authorities if you accept a job or become self-employed. Theyll want to know when your job starts and stops and how many hours you plan to work.
Based on this information and your disability, theyll grant you a trial work period for up to nine months. Be sure to tell them if you have expenses related to your disability, such as medications or a wheelchair. Make sure you tell them if these charges change as well.
Do You Automatically Get Medicare And Medicaid With Disability
If you have enough work credits and limited income and resources, you can get SSI and SSDI. Most states link Medicaid qualification to SSI benefits. Medicare, on the other hand, relates to Social Security benefits.
Thus, individuals can receive both Medicaid and Medicare. In fact, the state may pay your Medicare premiums.
SSDI recipients get free Medicare Part A which covers hospital expenses. Yet, you will need to pay monthly premiums for Part B to cover provider visits. The same is true for Part D, which pays for prescription drugs.
If you have trouble paying for Part B, D, or co-pays, theres help available. The Extra Help with Medicare Prescription Coverage program assists low-income/resource individuals.
This applies if youre an SSI beneficiary and eligible for Medicaid. This pays Medicare premiums, deductibles, and co-payments, as well as prescription drug costs.
Unlike Medicaid, Medicare has a waiting period for people with disabilities. In most states, you must be qualified as an SSDI beneficiary for 24 months. After that time, you automatically qualify for Medicare.
The two-year count begins on the day youre accepted for SSDI. Thus, even if circumstances cause a delay in payments, the clock has already started.
For some people, their medical condition gives them immediate access to Medicare. This includes people with permanent kidney failure. The person must need regular dialysis or a transplant.
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Medicare For Disabled Persons On Ssi
If youve been approved for SSI, can you receive Medicare coverage? In most states, SSI claimants normally only receive Medicaid insurance. Keep in mind that Medicaid is based on asset and income limitations. Its a county- and state-administered program for low-income individuals that helps them pay for prescriptions and doctor visits every month. It may even pay for nursing home care in some circumstances.
If you receive SSI, will you ever qualify for Medicare? SSI recipients only qualify for Medicare coverage once you reach the age of 65 and if you only received SSI and no other disability payments. Once you reach 65 years of age, you can complete an uninsured Medicare claim and save your state from paying for Medicaid coverage. Instead, they reduce costs by paying your medical premium for Medicare.
Medicare also provides Extra Help for individuals with limited assets and income to cover prescription drug costs. Extra Help pays for the premiums and co-pays of a Medicare prescription drug plan. See the Social Security Administration website to apply.
Is It Mandatory To Sign Up For Medicare After Age 65
No, it isnt mandatory to join Medicare. People can opt to sign up, or not.
If you don’t qualify for Social Security retirement benefits yet, you may need to manually enroll in Medicare at your local Social Security office, online or over the phone when you turn 65. You can also apply online for your Medicare coverage at www.medicare.gov.
Enrolling in Medicare as soon as youre eligible ensures you get the subsidized health care you deserve without waiting periods or financial penalties.
If you continue to work for a company employing 20 or more people after you turn 65, you could delay your Medicare enrollment. Your employee group plan provides enough medical coverage while youre working, meaning you may be able to wait to sign up for Medicare once you retire without incurring any late penalties.
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What Is The Difference Between Medicare And Medicaid
Its important to know the difference between Medicaid and Medicare. Each state oversees its Medicaid program. Its designed to help Americans of any age who have low income.
The government-run federal health care entitlement program is Medicare. It serves Americans aged 65 and over who paid into the fund while working. Today, about 36.5 percent of Americans get Medicaid or Medicare benefits.
What Conditions Qualify As A Disability
No matter whether you have SSI, SSDI, Medicaid, ABD Medicaid or Medicare, the medical requirements are the same. First, you must meet the non-medical disability requirements. These are based mainly on your work history and social security taxes youve paid. Then, monthly disability benefits are paid if a medical condition is expected to last at least 1 year or result in death.
Different types of medical conditions that qualify as a disability for adults over age 18 are listed in the chart below. Note that the chart shows a general list. It doesnt include every condition that may qualify adults for social security disability. For a full list of qualifying conditions visit the Social Security Administration website Theres also a separate childhood listing that shows impairments for children with disabilities.
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Special Home And Community
The Special Home and Community-Based Services Waiver Group eligibility pathway allows states to extend Medicaid eligibility to individuals receiving HCBS under a waiver program87 who require the level of care provided by a nursing facility or other medical institution.88 This eligibility pathway is sometimes referred to as the “217 Group” in reference to the specific regulatory section for this group, 42 C.F.R. Section 435.217. States use the highest income and resource standard of a separate eligibility group covered by the state plan under which an individual would otherwise qualify if institutionalized. For example, states that offer the Special Income Level pathway described above can extend eligibility to waiver program participants with income up to 300% of the SSI FBR. States must use the income- and resource-counting methodologies used to determine eligibility for this same eligibility group. States may also apply Section 1902’s more liberal income-counting rules to this group.
If You Get Medicare For Disability And Then Return To Work
If you get Medicare due to disability and then decide to go back to work, you can keep your Medicare coverage for as long as youre medically disabled.3 And, if you do go back to work, you wont have to pay the Part A premium for the first 8.5 years.
Part A is premium-free for those with a disability and under 65 only if you get Social Security or Railroad Retirement Board benefits for 24 months or have ESRD and meet certain requirements.4
If youre 65 or older, Part A is premium-free if you or your spouse worked and paid Medicare taxes for at least 10 years, you already get retirement benefits from Social Security or the Railroad Retirement Board, or youre eligible for these benefits but havent filed for them yet.5
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Who Is Eligible For Medicare
Generally, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease . Medicare has two parts, Part A and Part B . You are eligible for premium-free Part A if you are age 65 or older and you or your spouse worked and paid Medicare taxes for at least 10 years. You can get Part A at age 65 without having to pay premiums if:
- You are receiving retirement benefits from Social Security or the Railroad Retirement Board.
- You are eligible to receive Social Security or Railroad benefits but you have not yet filed for them.
- You or your spouse had Medicare-covered government employment.
To find out if you are eligible and your expected premium, go the Medicare.gov eligibility tool.
If you did not pay Medicare taxes while you worked, and you are age 65 or older and a citizen or permanent resident of the United States, you may be able to buy Part A. If you are under age 65, you can get Part A without having to pay premiums if:
- You have been entitled to Social Security or Railroad Retirement Board disability benefits for 24 months.
- You are a kidney dialysis or kidney transplant patient.
While most people do not have to pay a premium for Part A, everyone must pay for Part B if they want it. This monthly premium is deducted from your Social Security, Railroad Retirement, or Civil Service Retirement check. If you do not get any of these payments, Medicare sends you a bill for your Part B premium every 3 months.