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  • Writer's pictureWade Scott

#5-Where Does Medicare Stop and Medicaid Pick Up?(1)

Traditional Medicare provides healthcare insurance for individuals who are 65 and older and for younger individuals who have qualifying disabilities. Generally, Medicare coverage involves necessary medical services, some of which may involve skilled care. Covered services are broken out into distinct parts:


Part A – covers inpatient hospital care, skilled in-patient care, skilled in-home care, and hospice care. Generally covered services are limited to a maximum of 100 days per medical event.


Part B – generally medically necessary outpatient services from a licensed healthcare provider, durable medical equipment, screening and counseling services designed to prevent illness, mental health services, testing, and chiropractic care.


Part D – outpatient drug coverage.


Supplemental Coverage Plans – pays outstanding deductibles, coinsurance, and copayments not covered by traditional Medicaid.


Medicare A and B are provided by the government. Part D and supplemental coverage plans are provided by private health insurance. Medicare A is the only free coverage. All of the rest have some level of premium that individuals pay.


At some point medically necessary care stops for most individuals because they have returned to their baseline of health. This is the point where Medicare stops. Other individuals continue to need care that is classified as custodial. These individuals are unable to return to their base line of health despite receiving skilled care services. Custodial care is provided by non-medical aides with activities of daily living. Medicare does not pay for custodial care.


Custodial care is paid for by Long-Term Care Medicaid or the patient self pays for it. Medicaid covers custodial care in the home or in a facility. In a sense, Medicaid picks up where Medicare leaves off. What is confusing about this is that there are multiple Medicaid programs, one of which provides health insurance to the financially disadvantaged. A person who is age 65 and older and is financially disadvantaged can qualify for both Medicaid and Medicare. This is known as dual eligibility. Medicare and Medicaid share the cost of medically necessary care. Long-Term Care Medicaid will cover the cost of non-skilled care for activities of daily living.


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(1) This blog does not get into the weeds about all things Medicare or Medicaid. It simply is giving the reader a way to understand the difference between traditional Medicare and Long-Term Care Medicaid.







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