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If you believe you may be eligible for needs-based government benefits, figuring out which programs you qualify for might seem like a daunting task. For example, Medicare and Medicaid are both run by the Centers for Medicare & Medicaid Services (CMS) and sound very similar. However, they vary in the individuals they assist. Below are the basics of each program.

Medicare is a federal health insurance program that is available to: people who are age 65 or older, certain younger individuals with disabilities, and people with permanent kidney failure requiring dialysis or a transplant.

Different parts of Medicare help cover specific services. Here are Medicare’s available services:

  • Hospital Insurance (Part A): Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working.
  • Medical Insurance (Part B): Part B helps cover doctors’ services and outpatient care. It also covers some other medical services that Part A doesn’t cover, such as some of the services of physical and occupational therapists, and some home health care. Part B helps pay for these covered services and supplies when they are medically necessary. Most people pay a monthly premium for Part B.
  • Medicare Advantage (Part C): Medicare Advantage includes both Part A and Part B. Private insurance companies approved by Medicare provide coverage, so beneficiaries may need to use health care providers who participate in the plan’s network.
  • Prescription Drug Coverage (Part D): Prescription drug coverage is available to everyone with Medicare. To get Medicare prescription drug coverage, people must join a plan approved by Medicare that offers Medicare drug coverage. Most people pay a monthly premium for Part D.

There are only certain times when individuals can enroll in Medicare. Some people may begin to receive Medicare coverage automatically, and others need to apply for benefits. The seven-month Initial Enrollment Period usually begins three months before the month you turn 65 (including the month you turn 65) and ends three months after the month you turn 65. If you’re interested in enrolling yourself or someone else to receive Medicare benefits, visit for more information.

It’s important to note that if you’re approaching settlement in a personal injury case and you’re a Medicare beneficiary, you may need to take action to maintain eligibility for Medicare benefits. A Medicare set-aside, for example, is established from a portion of the settlement amount and is used to pay for future injury- or illness-related medical expenses that would otherwise be payable by Medicare. More information on this settlement planning tool can be found here.

Medicaid provides coverage to eligible individual adults with low income as well as children, pregnant women, seniors, and people with disabilities.

States each establish and administer their own Medicaid programs and determine how much coverage a person can receive and for how long. Federal law mandates that the states carry certain benefits, which include the following:

  • Inpatient hospital services
  • Outpatient hospital services
  • EPSDT: Early and Periodic Screening, Diagnostic, and Treatment Services
  • Nursing Facility Services
  • Home health services
  • Physician services
  • Rural health clinic services
  • Federally qualified health center services
  • Laboratory and X-ray services
  • Family planning services
  • Nurse Midwife services
  • Certified Pediatric and Family Nurse Practitioner services
  • Freestanding Birth Center services (when licensed or otherwise recognized by the state)
  • Transportation to medical care
  • Tobacco cessation counseling for pregnant women

Optional Medicaid benefits include services like prescription drugs, respiratory care services, podiatry services, optometry, dental, and more. Each state has its own rules regarding these optional services.

Some states offer a program for those with health needs who have too much income to qualify for Medicaid. Individuals who are eligible for this program can “spend down” their income that is above their state’s standard. Medicaid beneficiaries who receive a personal injury settlement may also lose eligibility due to the extra income. A special needs trust is one way a person with an illness or disability can use to keep their settlement proceeds without being disqualified for Medicaid benefits.

If you believe that you or a family member is eligible to receive Medicaid benefits, start here.

Milestone Consulting helps people plan for their financial futures after concluding a lawsuit. If you’re a beneficiary of needs-based government programs, we can give you the advice you need to plan for the incoming settlement, so you can continue receiving your benefits. We welcome you to give us a call if you’d like any assistance.

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