Long-Term Care Planning: Medicare and Medicaid
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Sometimes long-term care is described as separate from medical care or is seen only as nursing home or personal care at home. My definition of long-term care begins with what an individual needs, not who pays or who provides the service.
From that perspective, an individual needs both medical care and nonmedical services. Medicare pays for the medical care needed by someone who has a chronic condition or a disability but does not pay for the nonmedical services that person needs. Medicaid, however, pays for both for eligible people.
Here is an essential but still often misunderstood distinction between Medicare and Medicaid:
Medicare: A federal health insurance program for people aged 65 and older and younger people with certain conditions and disabilities. Over 50 million Americans are enrolled in Medicare.
Medicaid: A federal-state program that pays for healthcare and long-term care for low-income people. Over 70 million Americans, including more than one in three children, receive healthcare through Medicaid over the course of a year, and over 55 million are enrolled at any point in time.
Take a Look at Medicare Basics
Medicare is the main source of payment for medical care for retired or not-employed older adults.
If you or your parent live in your own home, assisted living, a multigenerational home, or some other non-nursing-home setting, you need access to medical care for primary care, preventive care, management of chronic conditions, hospital care, post-hospital rehabilitation services and home healthcare, and emergencies, as well as prescription drugs and, for some conditions, durable medical equipment. Medicare generally pays for this necessary medical care.
The Affordable Care Act (ACA, also commonly called Obamacare) does not affect Medicare eligibility. If you or your parent are enrolled in Medicare, you don't have to do anything. The ACA did make a few changes to Medicare: Some preventive measures such as mammograms and colonoscopies are now free, and a timetable has been set for closing the so-called doughnut hole in Part D for prescription drugs.
Are you eligible for Medicare?
If you or your parent is 65 or older, you are probably already enrolled in Medicare. Enrollment is automatic when you start collecting some form of Social Security benefits. If you are 65 or older and not yet collecting Social Security benefits, you have to enroll online, over the phone, or in person through the Social Security Administration.
However, not everyone over 65 is automatically eligible for Medicare. You have to be a U.S. citizen or a legal resident of the United States for over five years. Residents of Puerto Rico are eligible. If you (or a spouse) have worked at least a total of ten years (40 credits) and contributed to Social Security under the Federal Insurance Contributions Act (FICA) through your employers, you are eligible.
Earning 40 work credits only means that you don't have to pay monthly premiums for Part A services. Anybody who is a citizen or legal resident for at least five years can get Part B and Part D services by paying premiums for them like everybody else.
The U.S. Supreme Court ruling in June 2013 that struck down Section 3 of the Defense of Marriage Act has implications for Medicare eligibility. The Act had defined a spouse as a person of the opposite sex, so the Court's decision opens Medicare eligibility and benefits to same-sex couples.
The Department of Health and Human Services has begun to issue specific policy changes, including same-sex married couples’ rights under Medicare Advantage plans to reside in the same nursing home, regardless of whether that state recognizes same-sex marriages.
If you are uncertain whether you or your parent qualifies for Medicare, contact Social Security at 800-772-1213. The Medicare Rights Center has a useful fact sheet, Medicare Q and A on eligibility and the timing of enrollment.