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What is the Difference Between Medicare and Medicaid in New York?

On Behalf of | Oct 6, 2014 | Long-Term Care

It is important to know the distinctions between Medicare and Medicaid. With more than 70 million “baby boomers” coming of age, a growing number are now asking the question. Here’s a brief explanation:

Medicare is a program administered by the federal government that is available to persons who are sixty-five years of age and older, as well as certain disabled persons. Presently, Medicare provides health care for approximately 40 million elderly and disabled Americans. Since the passage of Title XVII of the Social Security Act in 1965, Medicare has basically been the health insurance component of Social Security. Medicare provides health insurance without any asset or income requirements

There are three separate components of Medicare:

Medicare Part A – covers the costs of in-patient hospital care, home health care, hospice care and some “skilled” nursing care. The hospital care must be determined to have been medically necessary.

Medicare Part B – covers part of the cost of physician services and other medical services and supplies. For example, if an individual is hospitalized, the hospital bill would be covered by Part A; however, the patient’s physician services would be covered by Medicare Part B.

Medicare Part C (Medicare Plus Choice) – this portion of Medicare was enacted to provide those eligible for Medicare to have the option of having physicians’ services provided to them by various health care providers such as HMOs.

For purposes of nursing home planning, it is important to remember that Medicare only covers a maximum stay in a skilled nursing facility for one hundred days, if the admission to the nursing home is within thirty days of the hospital discharge. The patient must require skilled nursing or skilled rehabilitative services on a daily basis. Of said one hundred days, Medicare will cover the first twenty days in full, and for the next 80 days Medicare will pay everything except $109.50 per day. Medicare does not provide any coverage for custodial care, which is generally most of the care a nursing home patient receives. This is where the need for Medicaid eligibility is of importance.

Unlike Medicare, Medicaid, which was enacted in 1964 by Title XIX of the Social Security Act, is a “means tested” entitlement program that is jointly administered by the federal and state governments. As a “means tested” entitlement program, Medicaid has income a resource limits as a pre-condition to eligibility. In order to participate in the Medicaid program, in 1965 New York State enacted the enabling legislation to effectuate the availability of Medicaid in New York.

In addition to the income and resource requirements for eligibility for Medicaid, residency is an additional prerequisite to eligibility. For purposes of Medicaid eligibility, residency is defined as the location where the applicant has his permanent home. Generally, to be eligible for Medicaid in New York, an individual must be a resident of the state. Although New York has no durational residency requirement, physical presence within the state and the intent to remain are all critical factors in establishing residency. Also, while it is not necessary that one be a citizen, it is necessary that one be a legal resident.

Finally, to be eligible for Medicaid it is necessary that an individual be under the age of twenty-one or over the age of sixty-five. Those between the ages of twenty-one and sixty-five can become eligible for Medicaid only if they are blind, disabled, eligible for public assistance, or recipients of Supplemental Security Income.