North Carolina Medicaid and Medicare Differences

Medicare vs. Medicaid – what’s the difference?

People often confuse Medicare and Medicaid in North Carolina. Knowing the differences between these separate and distinct programs, however, can help you to protect your loved one’s savings from high nursing home and health care costs.

Medicare is the federally-funded health insurance program designed to provide health care services primarily to individuals over the age of 65. Recent changes to the program have expanded benefits through Medicare managed plans. However, long-term custodial nursing home benefits have never been part of either managed care or traditional Medicare plans. After rehab ends, the program that might help with the nursing home bills is called Medicaid.

For example, suppose that your loved one is enrolled in traditional Medicare. What is available? In most cases, North Carolina Medicare will cover the first 20 days in a skilled nursing facility. In some circumstances, Medicare may cover the next 80 days of nursing home care, but with a deductible that is over $150/day. If your loved one has a Medigap insurance policy (also called a supplemental health insurance policy), days 21-100 are covered without a deductible, but only if your loved one meets strict qualification criteria.

We strongly recommend a complete review of your health benefits so that you can be prepared and understand the qualifying factors to receive services. If your loved one receives treatment and recovers, he or she may again be eligible for additional Medicare skilled nursing benefits.

It is difficult to predict how many days of skilled nursing care Medicare will cover in North Carolina. From our experience, we have found that our many clients do not receive benefits that extend to the 100-day maximum.

But even if you do receive the full 100 days, what happens when Medicare discontinues coverage and your loved one still requires around-the-clock care? The options that are typically available are either: long-term care insurance, payment from one’s own limited assets, or possibly coverage through the Medicaid program or through certain programs available through the Veteran’s Administration.

There are Health Maintenance Organizations (HMOs) that offer a Medicare +Choice program instead of traditional Medicare. These insurance companies use the Medicare reimbursement to provide additional services over what traditional Medicare provides. These are voluntary and are chosen by the Medicare recipient. There are strict enrollment rules. If a Medicare +Choice program is covering your family member with a condition that requires long-term care, it is very important to know the benefits offered and what the qualifiers are for the services. These programs are required to follow Medicare regulations, but can offer more services. Remember that the North Carolina Medicare +Choice programs are the “gatekeepers” instead of the physicians and, therefore, dictate when, where, and if services are authorized.