Medicaid Defined

Medicaid is a combined federal and state program that provides healthcare coverage to low-income groups, children, pregnant women, the elderly, people with disabilities, and low-wage workers without job-based insurance.

Eligibility

Eligibility varies in every state and is based on a number of factors, including citizenship status, residency, family size, and income. Beneficiaries typically have to be residents of the state and either citizens or eligible non-citizens of the United States, with special programs for children, pregnant women, the elderly, and those with disabilities. Although states establish their own standards within federal guidelines, income-based criteria are frequently in line with federal poverty levels. 

Funding Sources

The federal government and states work together to support Medicaid, with the federal government matching a predetermined portion of state spending. In order to sustain funding, states may impose provider taxes on hospitals and nursing homes in addition to using general revenue sources like taxes and intergovernmental transfers to pay their share. This arrangement divides costs between the federal and state governments while optimizing coverage for low-income groups.

Benefits

Medicaid provides coverage for required services such as home health care, laboratory and x-ray services, physician services, and inpatient and outpatient hospital care. Prescription medication, case management, physical therapy, and occupational therapy are examples of optional services. The program offers critical acute, long-term care, and preventative services while adapting to the demands of the state and its citizens. 

Administrative Structure

Medicaid is administered by a single state agency designated by each state, which frequently enters into service delivery agreements with other public or private entities. Despite being legally mandated, states maintain significant discretion over day-to-day operations under general federal regulations. States can customize programs while maintaining adherence to fundamental federal criteria, thanks to the joint federal-state administration.

Medicare

Medicare is a government health insurance program that primarily serves those 65 and older, as well as younger individuals with specific medical illnesses or impairments, such as end-stage renal disease (ESRD). 

Eligibility Criteria

The eligibility criteria include age, citizenship or legal permanent residency, qualifying disabilities or illnesses, and residency. The eligibility starts at the age of 65 for citizens of the United States and permanent residents.

Funding Sources

The U.S. Treasury’s dedicated trust funds, which support Medicare, consist of payroll taxes, general revenues, beneficiary premiums, and other sources. By combining government funds with required payments, funding mechanisms help ensure the program’s viability. 

Benefits

Medicare’s four components (A through D) cover hospital insurance, medical insurance, Medicare Advantage, and prescription drugs, respectively. Acute care, regular doctor visits, prescription medication coverage, and preventive services are all fully covered. 

Administrative Structure

The Centers for Medicare & Medicaid Services (CMS) is responsible for administering Medicare. CMS contracts with private insurers, called Medicare Administrative Contractors (MACs), to manage claims, appeals, and reimbursement rules at the regional level. This federal-private cooperation aids in the effective administration of Medicare provider payments and service delivery.