Medicare and Medicaid are the two government-sponsored health care programs. Medicare is generally available to most citizens who are disabled or at least 65 years old. There are three main types of Medicare: hospital insurance (Part A), medical insurance (Part B) and prescription drug coverage (Part D). Medicaid is a need-based program that is available to those who, regardless of age, meet certain financial requirements.
You are eligible for Medicare if you or your spouse worked for at least 10 years in Medicare-covered employment, are at least 65 years of age, and you are a citizen or permanent resident of the United States. You can also qualify if you are a younger person with a disability, or you suffer from an end stage renal disease. Medicare is divided into several programs: Part A, Part B, Medicare Advantage, and Medicare Part D.
PART A: Part A is hospital insurance which helps pay for care in hospitals, skilled nursing facilities, hospice, and some home health care. Anyone who is at least 65 years old and receives Social Security or Railroad Retirement Benefits is eligible for Medicare Part A coverage. This includes a retired worker or a survivor or dependent of a retired worker who receives benefits.
Those receiving disability benefits from Social Security are also eligible for Medicare Part A. A person under 65 who has been receiving disability benefits for more than two years is eligible for Medicare Part A. The months you are disabled do not have to be consecutive. If you have End-Stage Renal (kidney) Disease you are also eligible for Medicare Part A. If you need dialysis, you must first serve a waiting period before you are eligible for benefits.
If you are in any of the above groups, you can get Medicare Part A coverage without paying any monthly premiums. If you are at least 65 years old and you do not fall into one of the categories above, you can pay for Medicare Part A coverage. If you participate in this voluntary pay system, you have to pay a monthly premium. Those paying for Medicare Part A are required to purchase Part B coverage as well. The monthly price for this coverage is set each year by law. Additionally, those paying for Medicare Part A are required to purchase Part B coverage as well.
Finally, the state must buy Medicare Part A and Part B coverage for some Medicaid recipients. This coverage is extended to Medicaid recipients that meet certain income requirements. You may qualify for a Medicare assistance program as a Qualified Medicare Beneficiary (QMB), Specified Low-Income Beneficiary (SLIMB), or Qualifying Individual (QI-1). The state pays the QMB’s Medicare premiums, deductibles, and coinsurance. The state pays the SLIMB’s Medicare Part B premium. The state pays a QI-1’s monthly Part B premium.
PART B: Medicare Part B is called supplemental medical insurance. Medicare Part B covers physician services, outpatient services, home health care, and some laboratory and diagnostic services. Part B Medicare coverage is voluntary, and you must pay a monthly premium to receive coverage.
Those who receive Medicare Part A are eligible for Part B. Also, anyone who is a U.S. resident and is at least 65 years old can participate. Additionally, those who have been legal aliens for more than 5 years can apply. The monthly premium is set by law, and it increases when your income is above a certain level. Social Security will notify you by mail if your premium will increase because of your income.
Medicare will pay benefits to an insurance provider rather than straight to you. The providers are private insurance companies. Medicare will only pay for services under Part A and B that are reasonable and necessary. If you have questions about your eligibility or premium for Medicare Part A or Part B, or if you want to apply for Medicare, call the Social Security Administration at 1 (800) 772-1213.
Medicare Advantage: If you have both Parts A and B, and you do not have End-Stage Renal Disease, you may be able to participate in a Medicare Advantage Plan, formerly known as Medicare + Choice. Medicare
Advantage Plans will give beneficiaries an expanded set of options and include Medicare managed care plans (like HMOs) and Medicare Private Fee-for-Service plans. With the Medicare Advantage Plan, you may be able to get extra benefits, like prescription drugs, dentures or denture care, eyeglasses, hearing aids, long-term nursing care, custodial care, or additional days in the hospital. However, you may have to pay more money for a Medicare Advantage Plan, and you may only be able to go to certain doctors or hospitals that agree to treat plan members. For more information, call The Centers for Medicare and Medicaid Services at 1 (800) 633-4227.
PART D: Medicare Part D is optional prescription drug coverage. Anyone who has Medicare A or B coverage is eligible to enroll in a Medicare Part D plan. Unlike other parts of Medicare, coverage is not available directly from Medicare. If you wish to enroll in prescription drug coverage, you must choose a Part D plan from a private insurance company. There are numerous different plans available to West Virginia residents, each with different premiums, deductibles, and co-payments. There are 3 tiers of “extra help” available to cover these costs if you have limited income and assets. To get extra help, you must apply through the Social Security administration. Qualified individuals who are dually-eligible (meaning they also receive Medicaid) are automatically enrolled in the tier of extra help that gives the individual the lowest co-insurance costs.
Medicaid is a need-based program. As a result, you must meet income and asset requirements to qualify for Medicaid coverage. Once you meet these requirements, Medicaid will pay your medical expenses.
Medicaid is administered by the West Virginia Department of Health and Human Resources (DHHR). Even though the program is funded mostly by the federal government, DHHR is responsible for running the program in this state. Although Medicaid is not limited to the elderly and disabled, for our purposes, we will only consider Medicaid eligibility for the elderly.
If you receive SSI, you are presumed to meet the eligibility requirements for Medicaid in West Virginia. If you do not receive SSI, you can still receive Medicaid assistance, but it may be very difficult. You must meet certain income and asset requirements. Medicaid coverage for nursing home care is slightly different. In that situation, you are allowed a higher income. You are also allowed to keep more assets if you have a spouse who lives at home.
For more information, see: 42 U.S.C. §§ 1395c, 1395y(a)(1)(A)-(N), 1396a(a)(10)(E), 1396d(p) (2015); 42 C.F.R. §§ 400.200, 406.5(a), 406.10, 406.12, 406.13, 406.32, 407.40 (2015); Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, Medicare & You (2011), http://www.medicare.gov/Publications/Pubs/pdf/10050.pdf (last visited May 28, 2015); West Virginia Department of Health and Human Resources, Income Maintenance Manual, §§ 10.2, 10.22, 11.2-.4, http://www.wvdhhr.org/bcf/family_assistance/policy.asp (last visited May 28, 2015); Joan M. Krauskopf et al., Elderlaw: Advocacy for the Aging §§ 10.1, 10.12, 10.14, 10.17, 10.18, 10.19, 10.20 (2nd ed. 1993); Centers for Medicare and Medicaid Services, Get Help With Your Medicare Costs, http://www.medicare.gov/Publications/Pubs/pdf/10126.pdf (last visited May 28, 2015).