Medicare and Medicaid Services

Although Medicare and Medicaid are two governmental programs, administered by the Centers for Medicare and Medicaid Services, they strikingly differ from each other in terms of the medical and health services, they mete out and the specific groups of Americans, they serve. Medicare is a social insurance program that predominantly caters to the older enrollees, aged 65 and above. Medicaid, on the other hand, is a social welfare program designed exclusively for the underprivileged mass.  Both the programs leaped into action, when President Lyndon B. Johnson signed amendments to the Social Security Act on July 30, 1965.

The State decisions always preside over their Federal counterparts, especially when it comes to the provisions of their Medicaid plans.  However, the Federal Government has mandated certain requirements that must be fulfilled by the States in order to receive Federal grants. Some of these services include:

 i) In-patient Hospital & General Hospital Services

ii) Prenatal Check-Up & Care

iii) Childrens’ Immunization Services

iv) Services Of Qualified Doctors, Consultants & General Physicians

v) Nursing Facility Services For Young Adults, Aged 21 Or Above,

vi) Health & Clinic Services For The Rural Population

vii) Laboratory & X-ray Services

viii) Family Planning Services, Services Provided By Trained Nurses & Midwives

ix) Health-Center & Ambulatory Services, Approved By the Federal Government

x) Services Provided By Family Nurse Professionals

xi) EPSDT Services For Children, Aged Below 21

xii) Pediatric Services

Although the States have to abide by the rules and regulations, laid out by the Federal Government, they have the license to provide Medicaid coverage to other similar groups that include:

i)Babies Up to Age 1 And Expectant Mothers, Whose Family Income Is Considerably Low

ii) Eligible Children & Young Adults, Aged Below 21

iii) Institutionalized Individuals, Who Live in Poverty & Depravity

iv) Certain Working Disabled Persons With Limited Income &Resources

v) Eligible Individuals, Suffering From Tuberculosis

vi) Certain Uninsured Or Disadvantaged Women, Who Have Undergone Screening For Breast Or Cervical Cancer

vii) Selected “Medically Needy" Persons, Who Are Not Below Poverty-Line

Medicaid, a dual federal-state program, was primarily designed to provide health insurance coverage to low-income and disadvantaged individuals, including children, expectant mothers, parents of eligible children, and disabled individuals. The State, by virtue of this program, pays the health care providers directly. The payments can be made via a fee-for-service agreement or through prepayment arrangements, such as health maintenance organizations (HMOs). However,Medicaid does not cater to every poor family, living under the American sun. This is because poverty alone does not qualify a person to apply for Medicaid assistance unless, he belongs to one of the pre-defined eligibility categories. Moreover, the Medicaid eligibility categories are numerous and exceedingly complicated because within each category, there are requirements other than income alone, which must be fulfilled. The candidature is weighed against a number of factors, including age, pregnancy, disability, blindness, income, resources as well as one’s citizenship and immigration status in the US. States may even impose a meager deductible, coinsurance, or copayment on some Medicaid beneficiaries for certain special services, they opt for. In fact, research confirms that about 60% of America's poor are not covered by the program.

Medicare, a Federal health-insurance program, pays for hospital and medical care for the older population as well as certain Americans, who meet other special criteria. To be eligible for Medicare, an individual must either be at least 65 years old or under 65 and disabled. Younger Americans, with End-Stage Renal Disease, can also apply for the program. To be eligible for Medicare, one has to be an US citizen or a permanent legal resident for 5 consecutive years. In addition to that, one must qualify for Social Security benefits with at least ten years of payments, contributed into the system.

The Medicare program is split into two main parts for hospital and medical insurance (Part A and Part B). Its other two parts are highly elastic and mainly provide for prescription drugs (Part C and Part D).One can opt forMedicare Part A or Hospital Insurance (HI) without having to pay a monthly premium. It mainly covers hospital stays with facilities including food, supplies, testing, a good and almost private room as well as home health care.

To opt for Medicare Part B or Supplementary Medical Insurance, one has to pay a monthly premium and an annual deductible way before the actual coverage. It mainly bears the cost of medically necessary physician visits, outpatient hospital visits, home health care and accessory services for the aged, infirm and disabled. It primarily covers: Sturdy Medical Gears, Services Rendered By Doctors & Nurses, X-rays, Chemotherapy, Specific Immunizations, Blood Transfusions, Renal Dialysis, Outpatient Hospital Services, Ambulance Transportation, Laboratory & Investigative Diagnosis, Immunosuppressive Drugs In The Wake of Organ Transplantation, Particular Hormonal Treatments, Prosthetic Equipments & Spectacles. Medicare Advantage Plan, also known as Medicare Part C, gives users lots of room and flexibility, enabling them to tailor a plan, in perfect harmony with their medical needs. 

Medicare Part C plan always comes with an inventory of private insurance companies that provides partial coverage. However, the details are prone to changes and variations, in line with the program and patient’s eligibility criteria. Some Advantage Plans, in close collaboration with health maintenance organizations (HMOs) or preferred provider organizations (PPOs), mete out preventive health care as well as specialist services to their beneficiaries. Medicare added another brand new prescription drug plan, to its gamut of services and solutions. It is now known as Medicare Part D, participation in which mandates the payment of a premium as well as a deductible.

Medicare is partially funded by payroll taxes, imposed by the Federal Insurance Contributions Act (FICA) and the Self-Employment Contributions Act of 1954. In case of employees, the tax is approximately 3% of their salaries, usually half borne by the employee and half sponsored by the employer. Premiums, deductibles, coinsurance, and copays are extra sources of payment for Medicare services.