EMAIL SIGN UP
Online Insurance Guide

INSURANCE ADVOCACY AND EDUCATION

Welcome to our Online Insurance Guide! Whether you’re a patient, family member or medical professional, you will find tools and materials that allow you to advocate for timely access to affordable treatment.

Use these resources to learn about insurance, troubleshoot insurance problems and connect with other patients who have overcome their own insurance challenges. 


Coverage Connection

Coverage Connection is PHA's monthly e-newsletter providing PH-related insurance updates. Read the latest information below or sign up to receive monthly updates via email.

Medicare vs. Medicaid: Understanding the Difference

Despite the fact that Medicare and Medicaid are both government health insurance programs with similar sounding names, the programs are structured differently and serve different purposes. Knowing a bit about them can help you make the best use of the benefits for which you are eligible.

Funding and Regulation

One way that Medicare and Medicaid differ is how they are funded and regulated. Medicare is funded and regulated at the federal level so eligibility criteria and other guidelines are the same across the country. Medicaid is funded jointly by state and federal funds. While some basic Medicaid services and criteria are mandated at the federal level, states have a lot of flexibility to implement Medicaid programs as they see fit. The programs vary significantly from state to state, and even may have different names.

Eligibility Criteria

Generally speaking, you are eligible for Medicare once you have turned 65, or if you have been on Social Security Disability for 24 months. Eligibility for Medicaid is determined by each state, and is targeted towards low-income children, pregnant women, individuals with disabilities and the elderly. Some, but not all, states have expanded Medicaid to include all adults below a specified income level.

Some low-income individuals who have turned 65 or have been receiving disability benefits for at least two years may be dual eligible. Dual eligible recipients can get assistance with part of the premium and copayment costs that Medicare charges, and Medicaid can fill in gaps that are not covered by Medicare.

Covered Services

Medicare coverage can largely depend on the plan(s) you choose, and is divided into four parts. Part A covers hospital care, home health, and other inpatient services. Part B covers doctor’s visits, preventative care, lab tests and other outpatient services. Part D is private prescription drug coverage. Medicare Part C, also known as Medicare Advantage plans, enable Medicare recipients to purchase private health insurance which often encompasses many of the same services that Parts A and B cover under terms and conditions unique to the particular plan chosen. In some Part C plans, prescription drugs are covered as well. Original Medicare consists of Parts A and B, however, most PH patients will need to consider a Part D or Part C plan to cover their treatment.

Unlike Medicare, Medicaid coverage is typically all under one single program, providing inpatient and outpatient health care coverage, prescription drug coverage, and hospital stays. However, as previously mentioned, coverage policies for Medicaid vary by state.

How to Sign Up

Medicare: If you are turning 65 this year, you can sign up during your enrollment period, a 7 month period beginning 3 months before your 65th birthday, and ending 3 months after you turn 65. To find out more about applying for Medicare, visit www.Medicare.gov.

Medicaid: Nearly all 50 states and D.C. accept Medicaid applications over the phone and online. Find out if you qualify in your state.

Find More Information

View our online insurance guide for more information about Medicare, Medicaid and other health insurance topics. Or Contact PHA’s Treatment Access Program, Insurance@PHAssociation.org or 301-565-3004 x773. Check out the chart below for an easy reference guide to Medicare and Medicaid.

 

Medicare

Medicaid

Funding & Regulation

  • Funded and regulated at the federal level
  • Eligibility criteria and other guidelines are the same for every state
  • Jointly funded by state and federal funds
  • States have flexibility
  • Some basic Medicaid services and criteria are mandated at the federal level

Eligibility

  • Generally eligible once you have turned 65
  • May be eligible If you have been on SSD for 24 months
  • Eligibility is specific to each state, but generally includes low-income and disabled adults, women who are pregnant, children and families.

Covered Services

Largely depends on the plan(s) you choose. May include:

  • Part A: covers inpatient services such as most medically necessary hospital, home health, and hospice care
  • Part B: covers doctor’s visits, durable medical equipment, lab tests, and other outpatient services
  • Part D: Private prescription drug coverage
  • Part C: usually combines coverage from Part A and B. May include Part D coverage as well

Largely depends on the state in which you reside. There are some mandatory benefits mandated by federal guidelines. These include:

  • Medically necessary nursing home care and home health care
  • Physician services
  • Lab tests and X-rays
  • Transportation to medical care
  • Rural health clinic services

How to Sign Up

  • If you are 65 and receiving Social Security benefits or Railroad Retirement benefits, you will be automatically enrolled in both Medicare Part A and Part B.
  • www.Medicare.gov
  • Sign up through the Health Insurance Marketplace (if applicable)
  • Through your state Medicaid agency
  • See if you qualify here

 

DISCLAIMER: The Insurance Resources section includes brief summaries of complex subjects. They should be used only as overviews and general guidelines. The views expressed herein do not necessarily reflect the policies or legal positions of the Pulmonary Hypertension Association. These summaries do not render any legal, accounting, or other professional advice, nor are they intended to explain fully all of the provisions or exclusions of the relevant laws, regulations, and rulings of various private and public insurance programs. Original sources of authority should be researched and utilized.
Contact us with insurance questions, success stories or suggestions.
PHA is proud to be able to make educational materials and programs like these available for free to everyone because of the generous support from members of the community just like you. Donations are welcome!

FacebookTwitterInstagram iconLinkedInYouTube

For optimal viewing of PHAssociation.org, please use a standards-compliant browser such as Google Chrome or Firefox.

The information provided on the PHA website is provided for general information only. It is not intended as legal, medical or other professional advice, and should not be relied upon as a substitute for consultations with qualified professionals who are familiar with your individual needs. PHA does not endorse or recommend any commercial products or services.

801 Roeder Road, Ste. 1000, Silver Spring, MD 20910   Patient-to-Patient Support Line: 1-800-748-7274
Webmaster@PHAssociation.org
    Privacy Policy    Provide Feedback & Report Bugs

Designed by Matrix Group International, Inc.® | © 2016 Pulmonary Hypertension Association. All Rights Reserved.

NORD

The National Organization for Rare Disorders (NORD) awarded PHA the Abbey S. Meyers Leadership Award in 2012 for outstanding service to PHA members in advocacy, education and other key areas.