Medicaid and Medicare funding

Medicaid

Medicaid is a joint Federal and State program that pays for health care for eligible benificiaries (e.g., disabled, low-income). Acceptance into Medicaid allows a patient to sign up for the NM Managed Care Program (Salud!) and join a Managed Care Organization (MCO). Salud! members receive healthcare services from in-network doctors, pharmacies, and hospitals. Medicaid may also pay the coinsurance, deductibles and premiums for Medicare Part A and Part B.

Medicare

Medicare is a federal health insurance program primarily for those 65-years and older, receiving Social Security benefits.

• Part A: Helps pay for inpatient hospital care, hospice, and skilled nursing facility (SNF) care.
• Part B: Helps pay for doctor visits, some home medical care, medical equipment, rehabilitation therapy, laboratory tests, x-rays, mental health, ambulance services, blood, and some preventative services.
• Part C: Covers Medicare Advantage Plans that are administered either as a Health Maintenance Organization (HMO) or Preferred Provider Organization (PPO). Part C is optional and may enable recipients to expand their covered healthcare benefits.
• Part D: Helps pay for prescription medications. (Note, most Medicare Advantage Plans also cover prescriptions.)

(Note: Parts B and D are optional. However, waiting to sign-up for them often results in increased monthly premiums. Medicare does not pay all of one's healthcare costs. Recipients usually pay monthly premiums and co-pays.)

Medicare can come in multiple configurations, including the original plan (Parts A and B), a Medicare Advantage Plan, or a Private Fee-for Service (PFFS) plan. Note, that the PFFS may cover more items, but the PFFS and not Medicare decides how much a recipient will pay in premiums and co-pays.

Medicare does not cover all healthcare costs. If a patient has Parts A and B, they may want to invest in Medigap to pay for items and co-pays not covered by Medicare. Medicaid covers most gaps in insurance left by Medicare. Note, that Medicare does not pay for long-term term health care, like nursing homes and home health aides. Such items are covered by Medicaid (when eligible) or long-term health insurance.

State Health Insurance Counseling and Assistance Programs (SHIPs) can answer patients' questions and aid them in choosing a plan that meets their needs.

Medicaid and Medicare Physician Pearls

• You, as a physician, must personally approve in writing an order recommending a patient be admitted to a facility.
• Medicaid will pay for a nursing home only if the patient has been shown to meet eligibility requirements (e.g., low income).
• A patient must be in the hospital for 3 midnights before they are eligible for SNF placement.

Links

NM Human Services Dept's Medical Assistance Division

P.O. Box 2348, Santa Fe, NM 87504-2348

- Phone: 505-827-3100 (SF) or 1-888-997-2583

- Email: MADinfo.HSD@state.nm.us

AARP on Medicaid and Medicare
- Phone: 1-888-687-2277

Centers for Medicare and Medicaid Services
- Phone: 1-800-633-4227

NM State Health Insurance Counseling and Assistance Program

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