Understanding Medicare and Medicaid Eligibility

Understanding Medicare and Medicaid Eligibility

The U.S. government sponsors programs were designed to provide health insurance for those who meet specific criteria. While Medicare and Medicaid may have similar sounding names, the two programs provide very different coverage. Although you may qualify and receive coverage from both Medicare and Medicaid, there are separate eligibility requirements for each program, and being eligible for one program does not necessarily mean you are eligible for the other. 

What’s the difference between Medicare and Medicaid?

Medicare Basics

Medicare is a federally supported, state-operated health care assistance program that pays for health care services. It typically covers some expenses related to a stay in a skilled facility but only after an inpatient hospital stay of “three midnights” and only for a related illness or injury. Visit www.medicare.gov for more information.

You may be eligible for Medicare if you or your spouse has paid into Social Security for at least 10 years. In addition, you must meet one of these requirements:

  • You are age 65 or over and receiving Social Security retirement benefits
  • You are under 65 with certain disabilities and have received Social Security disability benefits for 24 months
  • You are of any age but diagnosed with End Stage Renal Disease

Medicaid Basics

Medicaid is a means-tested health and medical services program for certain individuals and families with low incomes and few resources. Eligibility usually is based on extreme financial need and medical necessity. Because each state operates its own Medicaid program, eligibility requirements and coverage may vary from state to state.

Visit www.medicaid.gov  for more information.

Skilled nursing Medicare coverage

Medicare covers skilled nursing care if all of the following are true:

  • You have Medicare Part A and have days available in your benefit period.
  • You have a qualifying hospital stay. This means you were admitted to the hospital in a patient bed (not just observed in the emergency room) for three consecutive midnights or more. You must enter a SNF within 30 days of leaving the hospital. If you leave and re-enter the same or another SNF within 30 days, you do not need another three-midnight qualifying hospital stay to continue SNF benefits. This is also true if you stop receiving skilled care while in the SNF and then begin receiving skilled care again within 30 days.
  • A doctor has decided you need daily skilled care which must be given by, or under the direct supervision of a skilled nursing staff. If you are in a SNF for rehabilitation only, your care still is considered daily even if these therapy services are only offered 5-6 days/week.
  • You receive services in a SNF that has been certified by Medicare.
  • You need skilled services for a medical condition that was treated during a qualifying three-midnight hospital stay or began while you were receiving Medicare-covered SNF care. For example, if you are in the SNF because of a stroke and you fall and break your wrist, Medicare also will cover the treatment of your wrist.

How long does Medicare cover skilled nursing care?

While Medicare covers up to 100 days of skilled nursing care if you continue to meet Medicare requirements, our goal is always to help you return to your highest level of independence as soon as possible.

DAYS 1 THROUGH 20:  All services covered

DAYS 21 THROUGH 100: A daily co-payment is required*

AFTER 100 DAYS: No benefit

*Consult with the nursing home Admissions Director for your co-pay amount, which is subject to change each year. If you have a Medigap policy with the original Medicare plan or are in a Medicare managed care plan, your cost may be different or you may have additional coverage. Check your plan.