Medicare and Medicaid

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Hi nurses! I am a new nurse and I am having a hard time with medicare and medical. Can somebody explain to me the difference of Medicare and Medicaid? and examples would be great...thanks! :wink2:

gillytook

207 Posts

Medicare is an insurance program for senior citizens. It is a national program that you pay for with every paycheck. You become eligible at 65. Medicaid is a need based medical program for all ages. It is a state run program that receives federal funding. It is based on income, lack of insurance, dependents and medical condition.

Examples: John Doe retires at 67 and goes on Medicare.

Jane Doe is pregnant and has no insurance and is at the poverty level. She gets state medicaid to pay for her prenatal care, delivery and the babies neonatal care.

lonelytoday

12 Posts

Now I got it. Thanks for the explanation!

Daytonite, BSN, RN

1 Article; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

here are the definitions from my him textbook, health information management of a strategic resource, 2nd edition by mervat abdelhat, sara grostick, mary alice hanken and ellen jacobs:

  • medicare - "government program funded through taxation that provides payment for health care services for the elderly and certain categories of illnesses; federally funded program that provides health insurance for the elderly and certain groups; established in 1965 by title xviii health insurance for the aged of the social security act f 1935, now referred to as medicare; entitlement program (title xviii) enacted by the u.s. congress and effective july 1, 1966, as an amendment to the social security program. it provided health care payment for all participants 65 years of age or over." according to their website (http://www.cms.hhs.gov/medicaregeninfo/) medicare is for:
    • people age 65 or older,
    • people under age 65 with certain disabilities, and
    • people of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant).

    [*]medicaid - "jointly funded program between the state and federal governments to provide health care to welfare recipients in the different states; originally titled the medical assistance program; established by title xix of the social security act; entitlement program (title xix) that provides health care for low-income people." according to their website (http://www.cms.hhs.gov/medicaidgeninfo/):

    • medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. medicaid does not pay money to you; instead, it sends payments directly to your health care providers. depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services. ("medicaid at-a-glance 2005" may be downloaded from the bottom of the page.)

      medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services. read more about your state medicaid program. (see related links inside cms at the bottom of the page.)

      many groups of people are covered by medicaid. even within these groups, though, certain requirements must be met. these may include your age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a u.s. citizen or a lawfully admitted immigrant. the rules for counting your income and resources vary from state to state and from group to group. there are special rules for those who live in nursing homes and for disabled children living at home.

      your child may be eligible for coverage if he or she is a u.s. citizen or a lawfully admitted immigrant, even if you are not (however, there is a 5-year limit that applies to lawful permanent residents). eligibility for children is based on the child's status, not the parent's. also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child.

      in general, you should apply for medicaid if your income is low and you match one of the descriptions of the eligibility groups. (even if you are not sure whether you qualify, if you or someone in your family needs health care, you should apply for medicaid and have a qualified caseworker in your state

      medicaid does not provide medical assistance for all poor persons. even under the broadest provisions of the federal statute (except for emergency services for certain persons), the medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups. low income is only one test for medicaid eligibility; assets and resources are also tested against established thresholds. as noted earlier, categorically needy persons who are eligible for medicaid may or may not also receive cash assistance from the tanf program or from the ssi program. medically needy persons who would be categorically eligible except for income or assets may become eligible for medicaid solely because of excessive medical expenses.

you can learn about either program and specific eligibility requirements by going onto their website and finding information about both programs. the above information came from: http://www.cms.hhs.gov/ - centers for medicare and medicaid services. the medicaid program is different in every state. there are some things that each state must follow that the federal government demands they must comply with, but because each state contributes half the funding each state is allowed to decide how the money can be distributed among the poor. medicare, on the other hand, is strictly controlled by the social security administration of the federal government with very few exceptions as to what is covered from state to state.

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