Medicare and Medicaid—Affordable Care Act focuses on coordinating efforts

Medicare and Medicaid are often confused for one another.  Medicare is a federal governed program that provides health insurance for those over the age of 65, people of any age who have kidney failure or long term kidney disease, or people who are permanently disabled.  There is no income test.  Medicaid, however, is a state governed program that provides health insurance for low income pregnant women, children under the age of 19, people 65 and older, people who are blind, people who are disabled, and people who need nursing home care.  There is an income test to receive Medicaid, as it is intended to provide health insurance to those with low incomes.  Some people qualify for both programs; people that receive both Medicaid and Medicare are called “dual eligible beneficiaries.”

When Medicare and Medicaid were first created, they were designed as distinct programs with different purposes. They have different rules for eligibility, covered benefits, and payment. Over the past 40 years, the Medicare and Medicaid programs have remained separate systems, yet a number of individuals utilize both programs for their health care. Many individuals become eligible for Medicare first, and then qualify for Medicaid as a result of an income-changing event. Others qualify for Medicaid initially and then in turn qualify for Medicare because of their age or disability.  Here are some statistics on these dual eligible beneficiaries:

  • More than 9 million Americans are enrolled in both Medicare and Medicaid programs
  • About 66% of those dual eligibles are over the age of 65
  • Total annual spending exceeds $300 billion dollars across both Medicare and Medicaid for dual eligibles’ services
  • Dual eligibles make up 15% of Medicaid enrollees but account for 39% of all Medicaid expenditures
  • Dual eligibles make up 16% of Medicare enrollees and account for 27% of all Medicare expenditures
  • 19% of dual eligibles live in institutional settings

The federal government is looking at ways to better serve dual eligibles while also reducing expenditures.   Section 2602 of the Accountable Care Act passed in March of 2010 created the Federal Coordinated Health Care Office, or Medicare-Medicaid Coordination Office.  This office was officially established on December 30, 2010 and plans to integrate benefits and improve the coordination between federal and state governments.  Fifteen states have been chosen to develop coordinated care models that can be replicated across the country (Georgia is not one of them).

Some of Hurley Elder Care Law’s clients that live in nursing homes have both Medicare and Medicaid.  We have worked with families to navigate the complex relationship between Medicare and Medicaid.  The biggest challenges seem to come when a client moves back and forth from primary care to acute care to institutional care.  Most of the clients also still have a Medigap (or Medicare supplement plan) in addition to traditional Medicare, Medicare Part D, and nursing home Medicaid.  These multiple plans make navigating difficult and often require multiple calls and re-submittals of bills to insurance companies.  Will this new Medicare-Medicaid Coordination Office help our clients?  We will wait and see, and I am guessing it will be a long time before residents of Georgia find out.

To learn more, visit http://www.cms.gov/medicare-medicaid-coordination