Excerpts from Ourselves Growing Older

GOVERNMENT INSURANCE (MEDICARE/MEDICAID):
"ENTITLEMENT" PROGRAMS

MEDICAID, THE STATE/FEDERAL PROGRAM:

POVERTY AND MEDICAL NEED

If you meet the standards of poverty or medical need established by your state, at any age, you may be eligible for certain benefits under Medicaid. These benefits are decided on, and paid for, jointly by the federal government and your state, if you can find a provider or a facility that will accept the level of reimbursement the state program offers. (Medicaid programs rarely reimburse at 100 percent of the rate most providers and facilities usually charge.) Many services are not office-based, especially the preventive services and screening tests most needed by older women, and may not be covered under Medicaid.⁴⁵ Increasingly, many specialists are scaling back the services offered under Medicaid,⁴⁶ and indigent women generally have little access to full-fledged specialists.⁴⁷

If you are in an acute medical crisis, you may become temporarily eligible for Medicaid because of medical need, and will become ineligible again as soon as the crisis passes. In many cases you must have proof in writing that you have exhausted most of your financial resources and all of your assets before you can become eligible permanently (even for needed nursing-home care), a process called "spending down" or pauperization. Despite recent efforts to develop plans for advance government financing of nursing-home care for elders, the practice of pauperization continues in most places.⁴⁸ Women go through this process most frequently.

MEDICARE, THE FEDERAL PROGRAM: AGE

If you are over sixty-five or permanently disabled, regardless of where you live and no matter what your income, you are probably eligible for Medicare, the federal program that was designed to provide medical care for the elderly. You pay Medicare (insurance) premiums, which usually appear as deductions from your social security check, and Medicare only covers about 40 percent of your costs. Some providers so not even accept Medicare patients because the rate of reimbursement is too low, and many services are not covered anyway. This means that at sixty-five you will still have to find a way to pay for almost half of your medical care. Because of deductibles and copayments you either pay out of pocket each time for the difference between what Medicare pays and the billed fees, or if you can afford it you can purchase a private insurance policy to cover part of this difference, sometimes called "Medigap" insurance. (See chart below.) Warning: while some states allow so-called "long-term care" insurance to be sold, it is usually very expensive and inadequate. Efforts to regulate long-term insurance have been uneven and largely unsuccessful.⁴⁹ Beware of TV ads.

WHAT’S THE DIFFERENCE?* Medicaid Poor people, old or young, on welfare/public assistance or in medical need; mainly children States decide eligibility (criteria vary; you prove poverty, citizenship, etc) Benefits vary in each state after basics, always changing State money plus federal money Office visits/outpatient care usually free: once pauperized, you usually pay nothing for services covered, drugs, etc. Some states charge some small fees Home care, hospice care** partly covered if available Hospitalization is free but only at certain hospitals; more days covered than Medicare Not all doctors, facilities accept Medicaid patients; few choices Nursing-home care covered indefinitely once you get in Medicare Older and certain disabled people, rich or poor, on Social Security, Railroad Retirement, or self-pay Federal criteria determine eligibility no matter where you live Benefits same in all states, but changed periodically Federal money only, but administered by private contractors/insurers Office/outpatient never free: Part B premiums deducted from Social Security checks; you pay all drug charges, more than half all provider costs Home care, hospice care** partly covered if available Hospitalization partly covered; Part A premiums deducted; most hospitals accept Medicare but days limited; you will be asked to pay part; if poor, sick enough, state may help temporarily (known as "medically needy" under Medicaid) Not all doctors accept Medicare patients or Medicare rates. Facilities’ and doctors’ rates vary; you pay differences or buy extra insurance if you can afford*** Limited days free skilled nursing home care in lifetime. *This is the way these programs still look as we go to press **See Dying and Death chapter *** Medigap insurance, supplementary insurance that you must pay for, is designed to help cover the difference between what Medicare will reimburse and what doctors and hospitals charge. It is expensive and may not even cover your needs.

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