insurance

rosey2007cna · Jul 8, 2010

I am sure that someone can explain it better then I can but I will try. Medicare is for folks that are at a certain age and getting social security. Medicaid is insurance for people who meet certain low income requirements.

bridezillatobe · Jul 8, 2010

Medicare is something those at a certain age or disability receive, there are different parts to it, and certain parts are required. Part A (req'd at age 65) is in-patient hospital stay, it becomes primary if you are not working and secondary if you are working, part B is outpatient, I believe, and part D is a supplement (ie you pay for it) and it is for your prescriptions. Medicaid is for those who make less than a certain amount of money per year, and is funded by tax payers, Medicaid is also what is provided in states that offer "healthcare for all" (such as Vermont). I worked in health insurance for years, but it was an HMO, so sorry if I got a couple things wrong! LOL

mamamerlee, LPN · Jul 8, 2010

You are not an insurance provider, and the best thing to say is that you are not familiar with what their insurance covers, they should contact their provider. Offer to get someone from billing, or a social worker to help them sort it all out.

These coverages are always changing, and nurses are not the best source of insurance info.

CT Pixie, BSN, RN · Jul 8, 2010

I work for an insurance company doing a medicare supplement policy.

Medicare is restricted to people who are of Social Security age and/or disabled people who collect Social Security. It is a Federaly funded program where as Medicaid is a State funded program. Medicare recipients can be any age, they must fall below a certain yearly income in order to get it.

Medicare Part A is for in-hospital coverage and is the 'free' part of Medicare.

Medicare Part B is for outpatient services, labs, diagnostic procedures, office visits, out pt surgery etc. There is a premium that Medicare recipients pay for part B. You do not have to take part B if you do not want to.

To correct what bridezillatobe said..medicare does not automatically become secondary if you are working, If you are on Medicare and are actively working and carry an insurance policy though your employment, your work insurance policy is primary and medicare pays secondary. If you are working and do not have an insurance policy through that job, medicare remains primary.

Here is the link from Social Security that explains it all: http://ssa.gov/pubs/10043.html

coolpeach · Jul 8, 2010

Before becoming a nurse I worked in medical collections. I can't explain Medicare better than the above poster did so I will leave it at that. Medicaid (in Texas at least) is for those who cannot afford insurance. People generally apply for it at the same time they apply for foodstamps etc. Elderly people may also have it in addition to their Medicare. Medicaid has branched out into managed care here and they have different names for different Medicaid plans (Amerigroup, Parkland plus) etc. This was a few years ago so it may have changed. Depending on the plan you picked it covers different things. There is also medicaid for those who have a terminal illness, and are using hospice which only covers certain things. In addition, there is medicaid that is only for pregnancy which only covers the woman for her pregnancy/childbirth. If a baby is born on medicaid he/she is automatically covered for the first year. As of a few years ago you had to make under a certain amount to be covered under medicaid, and had to reapply ever 6 months. It will only cover children to age 18 unless the child is a foster child then it covers them until 20 or 21. Medicaid only pays a small % of the total bill, and the rest has to be written off. It is against the law to collect the write off from the pt. I am told that its very hard to find doctors that accept medicaid here because it pays so badly. In addition, there are a ton of meds that they will not cover. They are always changing what is covered, and isn't covered. I would bill for someone one day, and the next day the rules had changed. In addition, there is a deadline to file so if the paperwork gets tied up, lost etc, and the provider doesn't file within the time frame the provider has to eat the bill.

CT Pixie, BSN, RN · Jul 8, 2010

I want to add..Medicaid will always be the last to pay on an approved claim if a person carries Medicare and Medicaid.

Bormio · Jul 9, 2010

The most important thing to know to differentiate these two programs is that Medicare is a federally funded entitlement program and Medicaid is operated and administered by each state, but is federally subsidized. As a nurse, or any other healthcare professional, you should be able to explain the difference between these two programs. Medicare does not pay for any services provided outside of the U.S. Each state administers their own Medicaid program and sets rules about who is eligible and how much they will reimburse and also determine the structure of the program. Within certain guidelines, the Feds subsidize Medicaid programs.

Also, Medicare, as an entitlement program, is not part of the "discretionary" portion of the federal budget. Social Security is also an entitlement program.

CT Pixie, BSN, RN · Jul 9, 2010

Medicare does not pay for any services provided outside of the U.S.

Not so.

This is taken directly from the Medicare and You 2009 book:

Medicare generally doesn't cover health care while you are traveling outside the U.S. (the "U.S." includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). There are some exceptions including some cases where Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the U.S. In rare cases, Medicare may pay for inpatient hospital, doctor, or ambulance services you get in a foreign country in the following situations:

1) If an emergency arose within the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat your medical condition

2) If you are traveling through Canada without unreasonable delay by the most direct route between Alaska and another state when a medical emergency occurs and the Canadian hospital is closer than the nearest U.S. hospital that can treat the emergency

3) If you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your medical condition, regardless of whether an emergency exists

You pay 20% of the Medicare-approved amount, and the Part B deductible applies.

You can see the book here: http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf

Trauma Columnist · Jul 9, 2010

As a nurse, I always said that if there were questions about insurance, they needed to be discussed with the social worker, case manager or billing.

That said, as an APN, I need to know what is covered by what insurance.

The US healthcare system is very complex and changes constantly. While all the above posters are correct to a certain degree, no one can keep up with the constant changes unless it is part of your job.

I would respectfully decline to discuss it further with pts/families.

cebuana_nurse · Jul 9, 2010

Thank you for all who replied. Really appreciate it! Next time they ask about insurance, I would forward them to social services. I don't want to be penalized for giving them wrong information.