What Is The Difference Between Medicare, Medi-Cal, and Medicaid?

Everyone who begins to investigate their long-term health care options quickly comes across these terms.  The following will hopefully help you understand what these terms are and the differences between them.

Medicare is a Federal program which provides basic health insurance to everyone over age 65, and people who are under 65 but are eligible for Social Security Disability benefits.

Medicaid is a joint Federal-State program which provides (among other things) long-term care for seniors.  Medi-Cal is what the Federal Medicaid program is called in California.  Thus, Medicaid and Medi-Cal are essentially the same thing.

This week we will look at the Medicare program, what it covers, and what it doesn’t cover.

Medicare

Medicare has several “parts.”  These include:

  • Medicare Part A, which is Hospital Insurance;
  • Medicare Part B, which is Medical Insurance;
  • Medicare Part C (Medicare Advantage), which was formerly known as Medicare + Choice;  and
  • Medicare Part D, which is prescription drug coverage.

Generally, people who are over age 65 and getting Social Security automatically qualify for Medicare Parts A and B.  Part A is paid for by a portion of Social Security tax.  It helps pay for inpatient hospital care, skilled nursing care, hospice care and other services.

Part B is paid for by the monthly premiums of people enrolled and by general funds from the U.S. Treasury.  It helps pay for doctors’ fees, outpatient hospital visits, and other medical services and supplies that are not covered by Part A.  This year, the monthly Part B premium (which is deducted from your Social Security payment) is $104.90

Part C (Medicare Advantage) plans allow you to choose to receive all of your health care services through a provider organization.  These plans may help lower your costs of receiving medical services (many plans have zero premium!) or you may get extra benefits for an additional monthly fee.  You must, however, have both Parts A and B to enroll in Part C.  Medicare Advantage plans are the private insurance plans you see commercials for all the time – especially during the Open Enrollment period between October and December of each year.  The Federal Government’s official Medicare website has a tool which can help you compare the various Medicare Advantage plans.  https://www.medicare.gov/find-a-plan/questions/home.aspx.

Part D (prescription drug coverage) is voluntary and the costs are paid for by the monthly premiums of enrollees and Medicare.  Unlike Part B (where you are automatically enrolled and must opt out if you do not want it) you must specifically enroll in an approved Part D plan by filling out a form and submitting it to your insurer.

 

Does Medicare Pay For Long Term Care?

NO.  After a 3 day hospital stay, Medicare pays 100% of the cost, but only for the first 20 days of skilled nursing care. For days 21 through 100, you are responsible for a co-payment.  As of this date, the daily co-pay rate is $148 per day.

But it gets worse:  After 100 days of care in a nursing home, Medicare stops paying altogether, and you are responsible for all future costs, unless there is a new 3 day qualifying hospital stay (which then re-sets the 100 day clock).

You also need to be aware that Medicare does not pay for “custodial care.”  If you or a loved one are in need of custodial care, it must be paid for either by writing a check, by private long-term care insurance, or by Medi-Cal.

 

Our next installment will address Medi-Cal.

David L. Lynch, an attorney with over seventeen years of experience as a litigator and transactional attorney, established Desert Elder Law in 2010. After moving to Rancho Mirage, Mr. Lynch was inspired by personal events to apply his unique skills to the needs of seniors struggling with the complexities of California’s Medi-Cal system. His goal for his clients is to help them obtain the benefits they are entitled to while also protecting their home and assets to the greatest extent possible. Prior to founding Desert Elder Law, Mr. Lynch practiced both as a sole practitioner and as an associate with a “Top Twenty” law firm as ranked by The American Lawyer magazine.