The Medicare and Medicare Basics33
Medicare covers medically necessary acute care, such as doctor visits, prescription drugs, and hospital stays. Except for specific circumstances, Medicare does not pay for most long-term care services or personal care, such as help with bathing or for supervision, which is considered custodial care.34 Medicare does not provide long-term care coverage or custodial care unless medical care is needed.
Medigap plans are intended to fill the “gaps” in Medicare insurance. However, even the most comprehensive Medigap plans do not cover long-term care needs. These policies currently do not pay for assisted living, Alzheimer’s disease, custodial care, personal care, or adult day care.35
Medicare Advantage plans generally cover specialized care, such as stays in a skilled nursing facility, hospice, respite care, and eligible home health services. Some Medicare Advantage plans now cover certain long-term care and at-home care services.36
Medicare provides benefit payments for three broad categories of treatment: hospital (emergencies and surgeries), medical (doctors and treatments), and pharmaceutical (medicines). Unlike Medicaid, Medicare is an entitlement program, meaning that everyone who reaches age sixty-five and is entitled to receive social security benefits also receives Medicare. Medicare also covers people of any age who are permanently disabled or who have end-stage renal disease. Medicare is financed by multiple tax-funded trust funds, trust fund interest, beneficiary premiums, and additional money approved by Congress.37
Medicaid, on the other hand, is a public assistance program that helps pay medical costs for individuals with limited income and assets. To be eligible for Medicaid coverage, you must meet the program’s strict income and asset guidelines. The Medicaid program is jointly funded by the federal government and states. The federal government pays states for a specified percentage of program expenditures, called the Federal Medical Assistance Percentage (FMAP).38 The most significant difference between Medicare and Medicaid in the realm of long-term care planning, however, is that Medicaid covers some of the costs of nursing home care, while Medicare, for the most part, does not.”39 40 Recent changes in the Centers for Medicare and Medicaid Services rules allow some expansion of long-term services and supports (LTSS) into Medicare Advantage (MA) Plans (also known as Part C Plans) for enrollees.
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