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Medicaid is Different from Medicare

how is medicare different from medicaid

Medicaid is the state and federal partnership that provides health coverage for selected categories of people with low incomes. Its purpose is to improve the health of people who might otherwise go without medical care for themselves and their children. Medicaid is different in every state.

Medicare is a federal health insurance program for people who are age 65 or older or disabled. It is administered by the federal Department of Health and Human Services. Centers for Medicare and Medicaid Services (CMS). Eligibility for Medicare is not based on the person's income or assets. For more information please visit the sites below.

Medicare Advantage Special Needs Plan (SNPS)

  • Under the Medicare Modernization Act of 2003 (MMA), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. Special needs plans (SNPs) were allowed to target enrollment to one or more types of special needs individuals identified by Congress as: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions.
  • SNPs offer the opportunity to improve care for individuals with special needs, primarily through improved coordination and continuity of care. SNPs can focus on monitoring health status, managing chronic diseases, avoiding inappropriate hospitalizations and helping individuals move from high risk to lower risk on the care continuum.
  • According to 42 CFR 422.107, organizations seeking to offer a SNP must have a contract with the State Medicaid Agency. The SNP is responsible for providing benefits, or arranging for benefits to be provided, for individuals entitled to receive medical assistance under title XIX.
  • SNPs are required to cover specified Medicaid State Plan benefits and Medicare cost sharing which includes deductibles, coinsurance, and co-payments. Members of the SNPs cannot be billed or held responsible for these costs.
  • SNPs are responsible for providing coordination of care for its members. Coordination includes but is not limited to:
    • Assist its members in obtaining required services;
    • Coordinate the delivery of benefits and services to its members;
    • Inform network providers of benefits and services which are to be provided to its members;
    • Train network providers on available benefits and services in order to ensure its members receive benefits and services;
    • Cover all costs incurred for benefits by

      its members.

For additional information regarding SNPs, please visit the CMS website.

Who can enroll in an SNP?

  • Qualified Medicare Beneficiaries (QMB) and QMB Plus eligible individuals can enroll. This includes full duals but excludes Institutional Care Program (ICP) eligible recipients.
  • Qualified Medicare Beneficiaries (QMB) means individuals that are entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for Social Security Income (SSI) eligibility, and are not otherwise eligible for full Medicaid. A QMB is eligible for Medicaid payment of Medicare premium deductible, coinsurance and copayment amounts (except for Part D).
  • Qualified Medicare Beneficiaries (QMB Plus) means QMBs with full Medicaid. These individuals are entitled to Medicare Part A, have income of 100% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance, and provides full Medicaid benefits.
    • Currently, SNPs are provided the opportunity to enter into a Coordination of Benefits (COB) Agreement instead of the standard contract.
    • Under the COB Agreement SNPs are not paid a pmpm.
    • The SNP coordinates and arranges the Medicare and/or Medicaid benefits and services for dual eligible beneficiaries who are members of the health plan’s SNP.
    • The Agency is responsible for cost-sharing obligations and wrap-around benefits for certain dual eligible beneficiaries who are members of the health plan's SNP.

    SNPs who would like to enter into a standard contract or Coordination of Benefits Agreement with the Agency for 2013 must complete the form listed below and return to Jennifer Barrett via email no later than April 13, 2012. Contracts/Agreements must be executed for the 2013 calendar year no later than July 1, 2012.

    SNPs not enrolled in Medicaid as an active Medicaid provider must complete the full "Florida Medicaid Provider Enrollment Application" found on the fiscal agent Provider Web Portal . how is medicare different from medicaid

Category: Insurance

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