A Quick Guide to the Difference Between Medicaid & Medicare

Medicare and Medicaid may sound alike, but the health insurance programs are wildly different. Here's a quick primer.

Medicare and Medicaid may sound alike, but these government health insurance programs are dramatically different from one another. Here’s a brief overview.

What Is Medicare?

Administered by the federal government, Medicare is a health insurance program primarily for adults who are 65 years of age or older and have paid into the Social Security system for at least 40 quarters (about 10 years). An individual who lacks the necessary work credits can also benefit from the program through their spouse, as can individuals who are younger than 65 but have received Social Security Disability Insurance payments for at least two years.

What Medicare Covers

There are different parts to Medicare that make it a veritable “alphabet soup.” For example, Medicare Part A covers mostly in-patient hospital care and provides a minimal benefit for skilled nursing care and hospice care. Medicare Part B covers the costs of outpatient care, such as doctors’ visits, lab tests and preventative care. Medicare Part C is the Medicare Advantage program and an alternative to Medicare parts A and B.

Like most types of insurance, Medicare parts A, B and C include co-pays and deductibles. Generally, the amount of income you earn and the amount of assets you own are irrelevant for participation, so paupers, billionaires and everyone in between can be eligible.

Surprisingly, given that Medicare is primarily a program for individuals 65 and older, the program covers just a small portion of the cost of a nursing home stay. At most, it fully covers the costs associated with the initial 20 days of a stay and provides only partial coverage for the next 80 days. In addition, for a stay to be covered, a patient must meet certain requirements.

For example, the patient must have been hospitalized for at least three consecutive days directly prior to receiving care at a nursing home and that care must be considered medically necessary. Because of these requirements, patients or their families are often forced to pay out of pocket for nursing home care or seek relief from Medicaid.

What Is Medicaid?

Medicaid (known as Medi-Cal in California) is a federal-state program. It primarily acts as a safety net for those who can’t pay for healthcare.

Seniors can participate in Medicaid if they pass three tests: a medical necessity test, an asset test and an income test.

The medical necessity test requires that skilled nursing care is necessary to address the patient’s medical needs. The asset test places strict limits on how much property a patient and the patient’s spouse can own while benefiting from Medicaid. The income test limits how much individuals and couples may earn to be eligible for Medicaid.

There are ways to get around these eligibility tests if you or a loved one can’t pass them but want Medicaid to help pay for the cost of a nursing home stay. However, doing so may require the help of an attorney who practices elder law. A relatively new kind of law, elder law can help individuals preserve their assets and qualify for Medicaid. (Disclosure: The Wiewel Law firm, in Austin, Texas, specializes in estate planning.)

Remember, Medicaid planning is a complicated process and even a small error can mean the program will refuse to help pay for the cost of a nursing home stay. Be sure to speak with an expert if you have concerns.

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Medicare for All: Definition and Pros and Cons

Here are the pros and cons of Medicare for All.

Medicare for All is a proposed new healthcare system for the United States where instead of people getting health insurance from an insurance company, often provided through their workplace, everyone in America would be on a program provided through the federal government. It has become a favorite of progressives, and was heavily championed by Senator Bernie Sanders (D-Vermont) during his runs for the Democratic presidential nomination in 2016 and 2020. If you are looking for help with medical planning under our current system, consider working with a financial advisor.

Medicare For All: How It Works

Sanders’ bill would replace all other insurance, with limited exceptions, such as cosmetic surgery. Private insurance, employer-provided insurance, Medicaid, and our current version of Medicare, would all be replaced by Medicare for All. The Affordable Care Act, commonly referred to as Obamacare, would also be replaced by Medicare for All.

Medicare for All is actually more generous than your current Medicare program. Right now, Medicare is for Americans 65 and older. They receive care, but they’re also responsible for some of the cost. However, Sanders’ plan would cover medical bills completed, with no financial burden on the patient.

Sanders’ Medicare for All would be a single, national health insurance program that would cover everyone living in the United States. It would pay for every medically necessary service, including dental and vision care, mental health care and prescription drugs. There would be no copays or deductibles, with the exception of prescription drugs, though the cost would be limited to $200 a year. There may also be additional out-of-pocket costs for long-term care.

The government would set payment rates for drugs, services, and medical equipment. Each year, the Secretary of Health and Human Services would come up with a national budget for all covered services and spending would be capped by that national budget. Just 1% of the total health spending budget would be used to provide job dislocation assistance for people working in the insurance industry.

Sanders’ bill includes a four-year phase-in during which increasingly younger people could buy into Medicare. It would work like this: 55-year-olds would be able to buy into Medicare in the first year, 45-year-olds in the second year and 35-year-olds in the third year. Out-of-pocket costs would be reduced for everyone buying into Medicare. There would also be a public option insurance plan offered to people of all ages through the Obamacare marketplaces.

Medicare for All is effectively single-payer healthcare. Single-payer health care is where the government pays for people’s health care. The new name just makes the concept more popular. A Kaiser Family Foundation poll found that 48% of people approved of single-payer healthcare, while 62% of people approved of Medicare for All.

Medicare for All Cost?

Here are the pros and cons of Medicare for All.

If everything stays the same as it is right now, the combined healthcare spending by private and public sectors is projected to reach $45 trillion by 2026.

The libertarian-oriented Mercatus Center at George Mason University estimated that the cost of Medicare for All would be more than $32 trillion over a 10-year period.

Kenneth Thorpe, a health finance expert at Emory University looked at a version of Sanders’ Medicare for All during the 2016 campaign and estimated that the cost would be about $25 trillion over 10 years.

In order to pay for the program, Sanders has suggested redirecting current government spending of about $2 trillion per year into Medicare for All. To do that, he would raise taxes on incomes over $250,000, reaching a 52 percent marginal rate on incomes over $10 million. He also suggested a wealth tax on the top 0.1 % of households.

Medicare for All Pros and Cons

Pros and cons for this program partially depend on your income bracket. If you make less than $250,000, Sanders’ additional tax will not affect you. If you make more than $250,000 a year, or are in the top 0.1 % of household, Sanders’ tax to pay for Medicare for All would be a con for you.

In addition, universal health care requires healthy people to pay for medical care for the sick. However, that is how all health insurance programs work. Everyone buys in and pays the costs of health insurance, but the insurance company only pays when someone needs medical care or coverage. In every insurance plan, healthier people absorb the costs incurred by sicker people.

Pros

  • Universal healthcare lowers health care costs for the economy overall, since the government controls the price of medication and medical services through regulation and negotiation.
  • It would also eliminate the administrative cost of working with multiple private health insurers. Doctors would only have to deal with one government agency, rather than multiple private insurance companies along with Medicare and Medicaid.
  • Companies would not have to hire staff to deal with many different health insurance companies’ rules. Instead, billing procedures and coverage rules would be standardized.
  • Hospitals and doctors would be forced to provide the same standard of service at a low cost, instead of targeting wealthy clients and offering expensive services so they can get a higher profit.
  • Universal healthcare leads to a healthier population. Studies show that preventive care lowers expensive emergency room usage. Before Obamacare, 46% of emergency room patients were there because they had nowhere else to go. The emergency room became their primary care physician. This type of health care inequality is a major factor in the rising cost of medical care.

 

Cons

  • Some analysts are concerned that the government may not be able to use its bargaining power to drive down costs as steeply and as quickly as Sanders predicts. Thorpe argues that Sanders is overly optimistic on this aspect of the bill.
  • Other analysts are concerned that insulating people from costs of care will drive up usage of medical care. Drew Altman, who heads the Kaiser Family Foundation, pointed out that “no other developed nation has zero out of pocket costs.”
  • People may not be as careful with their health if they do not have a financial incentive to do so.
  • Governments have to limit health care spending to keep costs down. Doctors might have less incentive to provide quality care if they aren’t well paid. They may spend less time per patient in order to keep costs down. They also have less funding for new life-saving technologies.
  • Since the government focuses on providing basic and emergency health care, most universal healthcare systems report long wait times for elective procedures. The government may also limit services with a low probability of success, and may not cover drugs for rare conditions. 

Other Medicare and Medicaid Expansion Bills

Lawmakers have introduced other Medicare expansion options, which would be much more limited than Medicare for All.

Senators Debbie Stabenow (D-Michigan), Sherrod Brown (D-Ohio) and Tammy Baldwin (D-Wisconsin) introduced the Medicare at 50 Act in February of 2019. Under the Medicare at 50 Act, people between 50 and 64 could buy into Medicare. Other than expanding the age, the main difference to our current Medicare program would be that coverage would automatically include Medicare Part A (hospital), Part B (physician), and Part D (prescription drug) coverage. In addition, you could choose Medicare offered through private insurers, known as Medicare Advantage. If you qualified for a premium subsidy under the Affordable Care Act, you would still be able to apply that to extended Medicare. This bill would effectively create a new insurance option for those 50 and older.

Senator Michael Bennett (D-Colorado) and Rep. Brian Higgins (D-New York) introduced a bill called Medicare-X Choice. This bill would offer Medicare to people of any age through the Obamacare marketplaces. This bill would not be initially enacted nationwide. Instead, the bill would focus on adding the Medicare option in places with few hospitals and doctors, or areas that only had one insurer offering coverage.

Senator Brian Schatz (D-Hawaii) and Rep. Ray Lujan (D-New Mexico) proposed a bill called the State Public Option Act that would let people buy into Medicaid, rather than Medicare. The details of covered services could vary from state to state, since this would be offered through Medicaid rather than Medicare. However, no plan would be able to offer less than essential health benefits covered under the Affordable Care Act.

Where the Presidential Candidates Stand

Here are the pros and cons of Medicare for All.

Sanders, of course, did not win the Democratic Primary. Joe Biden, widely considered significantly more moderate, won. Biden has an extensive healthcare proposal which expands many parts of the Affordable Care Act, but does not include a single payer Medicare For All program. Instead, it is based around a public option — a government plan only for those who want it, while private insurance companies remain the main driver of healthcare in the US.

President Donald Trump has not offered a comprehensive healthcare plan this time around. Early in his term, he and the Republicans in Congress tried to “repeal and replace” The ACA, but were unsuccessful.

 

The Bottom Line

Healthcare is certainly a hot topic for the 2020 election process. Though Bernie Sanders’ (D-Vermont) version of Medicare for All would eventually eliminate all other forms of insurance, other Democratic candidates have varying degrees of support and versions of Medicare for All  as a universal healthcare system. Though Medicare for All would likely lower the healthcare costs in the economy overall and increase quality care while also facilitating more preventative care to avoid expensive emergency room visits, you could end up paying more if you make more than $250,000 a year or are in the top 0.1 % of households. What’s more, some experts suggest that if costs are less onerous, patients will overuse the system and make setting up appointments for elective procedures more difficult.

Tips for Keeping Your Finances Healthy

  • A health savings account (HSA) may be a good option for younger people who are worried about potential healthcare costs. HSAs can greatly reduce monthly premiums.
  • Whatever the outcome on Medicare for All, it is important to keep yourself physically and financially healthy. If you are concerned about budgeting with health care costs, you may want to look into a financial advisor. SmartAsset can help you find your financial advisor match here.

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Questions to Ask When Shopping for Health Insurance

Whether you are acquiring it through your employer or on your own, shopping for health insurance coverage is a task that many adults will be faced with at some point. Health coverage is not a one-size-fits all amenity, and it comes in many forms such as Point of Service (POS), Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and more. 

Buying health insurance is a big commitment, so do the research and look over all your options before making any hasty decisions. Technical information about different health insurance policies can be overwhelming, which is why seeking the help of a licensed insurance agent or a health insurance broker might be your best bet. In the following sections we will discuss ways you can prepare to meet with a health insurance agent as well as what questions to ask. 

How to prepare to meet with a health insurance agent 

Health insurance exists to protect us financially when we get sick or injured, which is why it’s so important for you to look at plans that fit the unique needs of you and your family. Whether you are an employer shopping for insurance plans for your employees, or just an individual browsing your options, choosing a caring agent who takes their job seriously is key to finding the right plan. To start, you will want to work with an insurance agent who is experienced, knowledgeable and trustworthy.

Finding the right agent to work with isn’t the only important piece of the puzzle, you’ll also want to do your part as well. Coming prepared to the appointment will help things run more smoothly and will ensure that you to ask the right questions. 

Before meeting with the insurance agent, make sure that you:

  • Know how much you are willing to pay: Before your appointment with an insurance agency, you should consider how much risk you want to assume for yourself versus how much risk you want the insurance company to assume for you. In other words, would you rather make higher monthly insurance payments and have a lower deductible or would you rather pay a lower monthly insurance payment and have a higher deductible? If you’re okay with paying a hefty deductible during a medical crisis, then you might consider choosing a plan with a lower monthly payment. On the other hand, someone who needs more consistent medical care might opt for a plan with a lower deductible. 
  • Research the insurance agency that you will be doing business with: Ask friends and loved ones for feedback on the agencies they’ve worked with and find out how their experience was. If you are an employer, do some research to see what agencies other companies do business with. The important thing is that you choose an agency that you trust. 
  • Know what to bring with you: In order for the agent to help you the best they can, they will need to know as much information as possible about yours and your family’s medical history. The agent will want to know about any of yours or your family’s medical conditions and personal habits such as drinking, smoking, diet, etc. Call in advance and find out exactly what you need to bring. Be truthful and thorough so that your agent can find the best health insurance policy for you. 
  • Make a list of the questions that you will want to ask: It’s easy to get overwhelmed during these appointments. Writing down your questions will not only help you to be more organized, but it will also lower your chances of forgetting to bring up important topics.  

Questions to ask your health insurance agents

Before meeting with a licensed insurance agent, you should write down a list of questions that you want to have answered during your appointment. Here are some questions you should be asking your agent about your insurance before buying:

    • How much will it cost? This is probably the most dreaded part of the conversation, but it has to be discussed! The overall cost of your health insurance policy will depend on your premium, deductible and out-of-pocket-max. When browsing through plans, you’ll want to take notes on how much these three items will cost up front, because each plan varies in rates.
      • Premium: Health insurance premiums are rates that you will pay every month in order to secure your coverage. The initial payment you receive will be a premium, and will continue monthly. 
      • Deductible: If your plan has a deductible of $2,000, then that means you will be responsible for paying the first $2,000 of health care before your plan begins covering certain costs. Once you pay your deductible, you’ll pay significantly less for your health care. 
  • Out-of-pocket max: This is basically the maximum amount of money that you will ever have to be responsible for paying while covered—as long as you stay in-network, that is. Let’s say your out-of-pocket max is $5,000, but you end up needing surgery that costs $30,000. You would only have to worry about paying $5,000. Additionally, if you’ve already reached your $2,000 deductible, then you would only have to pay $3,000. The purpose of an out-of-pocket max is to protect you from having to pay extremely expensive bills, but remember—the surgery would need to happen at a medical facility that is in-network.  
  • Is my current doctor covered? If you’re already receiving health care, you’ll want to know if your current doctor is a part of any prospective insurance company’s network of health providers. This information should be fairly simple to find out but could be an important factor in your decision. If you are currently taking any medications, you’ll also want to ask your agent to check the formulary to see if your prescriptions are covered.
  • Who do I contact when I have questions? It’s important to find out if your prospective health insurance company has a customer service team you can call or message when you need to inquire about bills, claims, copays or anything else insurance-related. Does the company have a separate phone number to call when you want help finding a health care provider? Is this customer service line automated or will you be speaking to an actual insurance representative? These questions are important to determine what kind of support is available long after you’ve signed a contract. 

What happens during an emergency? When going to see a doctor for a normal visit, you have time to plan and make sure that the doctor is in-network. However, during an emergency, we may not have the same luxury. It’s possible that in a case where you need dire medical attention, the closest health care provider may not be in-network. You should ask about your prospective company’s policy on emergencies and what the standard routine consists of.

Questions to Ask When Shopping for Health Insurance is a post from Pocket Your Dollars.

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