Medicaid is Not a Herpes Cream

A health reform tutorial

Health care reform can be confusing
Health care reform can be confusing

Before becoming a nurse, I would have guessed that Medicaid was something you buy over the counter to rub on private ailments. More than anyone, I understand that the world of health policy can be confusing. Here’s a list of select terms to ease the pain of reading about health reform, (which you can do pain-free in this week’s news section here and here). Study up! At the very least, knowing the distinction between Medicare and Medicaid will help you impress bookishly cute fox at the coffee shop you’ve been eyeing.

Medicare: Government-run health insurance for the elderly and disabled. Medicare beneficiaries must meet certain eligibility criteria and typically pay premiums, deductibles and other out-of-pocket expenses to receive benefits.

Medicare Part A covers hospital-related stuff, while Medicare Part B covers other medical stuff like outpatient services and medical equipment. Medicare Part D covers prescription drugs.

The Medicare program also funds physician residency programs. The federal government funds Medicare.

Medicare Advantage: Also known as Medicare Part C. Medicare plans that are managed by private insurance companies. Instead of the government directly supplying a senior’s insurance, the senior can opt for an Advantage plan instead, where the government pays a private company to insure the senior.

Part D “donut hole”: Refers to the coverage gap for prescription drugs under Medicare Part D. Once Medicare beneficiaries have exceeded the prescription drug coverage limit, they are responsible for the entire cost of medications until they reach the “catastrophic” threshold. Medicare coverage kicks back in at the catastrophic threshold.

For 2009, Part D covered 75 percent of the cost of prescription drugs (after the beneficiary pays their $295 deductible) up until drug costs exceed $2,700. Drug expenses between $2,700 and $6,154 were NOT covered by Medicare, and the person had to pay 100 percent out of pocket. Once drug expenses exceeded $6,154, Medicare Part D kicked back in and covered 95 percent of the cost of drugs beyond this threshold. Many seniors get caught in the donut hole and pay thousands of dollars out-of-pocket for their medicines.

Medicaid: State-run insurance program for those with low incomes. The federal government sets certain regulations for Medicaid and supplies funds, but up to half of Medicaid funding occurs at the state level. Medicaid programs differ from state to state. Rather than being an entitlement program like Medicare (which all people over age 65 can participate in, regardless of income), Medicaid is a needs-based program.

Primary Care Providers: Primary care typically refers to the sector of the health care system that handles general medical concerns, prevention, screening and health/wellness promotion. Primary care providers serve as the “gatekeepers” into the medical system and refer more complicated patients to specialty services, such as neurology or dermatology.

Family physicians or general practitioners, pediatricians, some OB/GYNs, nurse practitioners and certified nurse midwives are examples of providers that often serve as primary care providers.