Have you ever noticed how, when the topic of Medicare and Medicaid come up, many of your friends seem to get a blank expression on their faces? Despite the fact that tens of millions of Americans are directly affected by these two legacy programs, the level of confusion and disinformation among the general public – and, yes, that includes seniors – is often surprising.
To cite just one example: according to a recent KFF study, more than 40 percent of all adults incorrectly believe Medicare is the primary source to pay for long-term care. Among respondents 65 and older, that figure jumps to a discouraging 45 percent. But that assumption is wrong.
Medicare and Medicaid serve different purposes, and Medicare tends to get more attention since it covers nine times more seniors – 62 million versus Medicaid’s 7 million, approximately. So, with so much misinformation out there, we thought it would be a good idea to review the basics: what Medicaid covers and what it doesn’t.
Our guide for this review is this blog article from a website called Legacy Navigation. It’s an Idaho-based Medicaid planning agency.
Declining Health, Income Strain are Prompting Questions
The blog article sets the stage. “You retired several years ago and have been relatively healthy,” it begins – “but lately, your health is starting to slip, requiring you to attend more appointments outside of your yearly physical. It’s getting harder for you to get around, and you don’t drive as much. Your children are grown and can’t always get time off work to help.”
On top of that, in this hypothetical situation, your healthcare costs are becoming a major burden on your retirement income. You decide that you’re going to need assistance to make your life easier.
Maybe Medicaid is the answer. But, you wonder, what does it cover? And how is it different from Medicare?
The Basic Elements of Medicaid Coverage for Seniors
The first thing to know, as the Legacy Navigation article explains, is that Medicaid is a partnership between the federal government and state governments. Each state’s Medicaid program is unique to that locale. About two-third of Medicaid funding comes from Uncle Sam with states covering the balance.
“The goal of Medicaid,” the blog article summarizes, “is to offer medical care and support services considered medically necessary and to keep older adults healthy and independent. These services may include doctor visits, medications, hospital visits, and supplemental services not covered by Medicare.”
As noted above, Medicaid currently provides vital care for approximately 7 million seniors.
The List of Medicaid-Covered Services is Extensive
The Legacy Navigation article lists seven categories of medical care covered by Medicaid. We’ve edited the list slightly for space. Note that coverage details and limitations vary state by state. The seven categories are:
Doctor visits: Routine doctor visits plus visits to specialists and emergency care.
Hospital stays: Medically necessary hospital stays, both inpatient and outpatient services.
Prescription medications: Prescription drugs including those not covered by Medicare.
Medicare cost-sharing: For Medicare-eligible low-income seniors to cover health care premiums, deductibles, and copays.
Supplemental services: Services such as dental care, vision care, immunizations, and limited transportation to medical appointments, especially for those with mobility issues.
Nursing home care: Skilled nursing care costs for eligible individuals. In some states assisted living is also covered by Medicaid.
Home and community-based services: Daily help for eligible seniors aging at home, such as mobility, meal preparation, and household tasks – plus help with activities of daily living (ADLs): bathing, toileting, dressing, walking, and eating or feeding.
Several Factors are Considered to Determine Medicaid Eligibility
You may think you qualify on paper for Medicaid benefits. But, according to the blog article we consulted, the only way to determine your actual eligibility is to apply, whether online, in person at your local Medicaid office, or by mail.
“Eligibility will be determined by either one or a combination of criteria based on your age, income level, the number of people in your family, and whether you have a disability,” says the Legacy Navigation article. “Eligibility requirements will vary depending on your state of residence.”
Besides a maximum income threshold, there are other criteria that suggest you might qualify for Medicaid benefits. These include blindness and disability. Those with low income and a diagnosis of breast or cervical cancer should also consider applying. One of the more obvious triggers is when your doctor decides you need skilled nursing care.
There are two ways to apply: directly with your state or through the health insurance marketplace (healthcare.gov). (For residents of Washington State, home to AgingOptions and Life Point Law, applications are handled by the Washington Health Care Authority.)
What Does Medicaid Not Cover for Seniors?
The Legacy Navigation notes that any list of covered medical services has to be broadly defined, since state coverage varies significantly. However, the blog article adds, there are some services which are typically not covered by Medicaid, no matter where you live.
Here are some common examples:
Elective cosmetic procedures: “Surgeries and procedures that are done to improve one’s appearance are not typically covered,” says the article. “These include procedures such as cosmetic dentistry or orthodontia, facelifts, tummy tucks, liposuction, or microdermabrasion.”
Non-emergency transportation: While many states deny transportation coverage for regular medical appointments, emergency transportation is typically covered.
Compensation for caregiving services by a household member: “Medicaid is not mandated to provide coverage for private nursing done by household members,” the blog article explains. “If it is covered, [Medicaid] may require proof of medical necessity and prior authorization.”
Medical supplies: Items such as bandages, adult diapers, or other disposable medical items are not typically covered by Medicaid.
Some People Qualify for Both Medicaid and Medicare Benefits
“If you meet the eligibility requirements for both Medicaid and Medicare, then you can be dual eligible,” says the Legacy Navigation blog. “This is often true for low-income seniors or people with disabilities.” About 13.7 million people currently have this dual eligibility.
“If you are over 65 and meet the income threshold, you would qualify for both Medicare and Medicaid,” the article explains. “In this case, Medicare would be used primarily for your healthcare needs, while Medicaid would be used for additional healthcare needs or long-term care services that Medicare doesn’t cover.”
Most if not all your healthcare costs would be covered, with Medicare as primary payer and Medicaid as secondary payer.
Our Advice: Don’t Assume Medicaid Eligibility is “Impossible”
One final note: our team at Life Point Law often encounters clients who think they couldn’t possibly qualify for Medicaid benefits. Often this assumption is based on a quick overview of income requirements or other financial factors.
But our advice is to consult with a qualified elder law attorney who is well-versed in Medicaid, before you make a hasty decision. The rules governing Medicaid can be complex, and there may very likely be helpful steps you can take to protect a significant portion of your assets and still qualify for benefits.
(As an example, see this recent Blog article about the Safe Harbor Trust – just one example of a planning tool that can affect Medicaid qualification.)
We encourage you to get the full story about Medicaid benefits and whether this program is right for you. Contact Attorney Aaron Paker at Life Point Law and learn the facts about Medicaid.
Rajiv Nagaich – Your Retirement Planning Coach and Guide
Rajiv Nagaich’s newest program on PBS, called Designing Your Ideal Future, is bringing Rajiv’s powerful message to Americans from coast to coast. This engaging and challenging PBS show is prompting thousands to take a fresh look at the type of planning that will help them succeed in retirement.
In this one-hour PBS special, Rajiv Nagaich takes viewers step-by-step through the principles of creating a retirement plan that truly supports the life you want to live. Instead of generic check-the-box paperwork, Rajiv reveals how to infuse your perspective — your values, goals, and priorities — into every legal document and life plan component so your plan becomes a living system for your future.
Designing Your Ideal Future includes insights from real-world planning examples and a live Q&A with Rajiv Nagaich that answers viewer questions about retirement planning, legal readiness, and family communication. It’s perfect for anyone approaching retirement, currently retired, or responsible for a loved one’s future care — and for those who want a clear, effective approach to planning that prioritizes personal choice and quality of life.
What about you?
You’ve heard Rajiv say it repeatedly: 70 percent of retirement plans will fail. If you know someone whose retirement turned into a nightmare when they were forced into a nursing home, went broke paying for care, or became a burden to their families – and you want to make sure it doesn’t happen to you – then these materials are your key to retirement success.
Visit your local PBS station’s schedule to find airtimes and learn how to access companion resources — including a free Legal Readiness Quiz and tools to help build your complete LifePlanning system.
Don’t remain among the millions of Americans sleepwalking their way into a retirement they never wanted. Instead, your retirement can be the exciting and fulfilling life you’ve always hoped it would be. Start by watching, reading and sharing Rajiv’s important message.
And remember, Age On, everyone!
(originally reported at https://legacynavigate.com)
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