Medicaid, Medicare, and Private Insurance

In this section you will find information and website links on Medicare, Medicaid, health insurance, long-term care insurance, and the Florida Department of Elder Affairs’ SHINE Program that provides counseling for seniors on health insurance.

First of all, following is a general comparison of Medicaid and Medicare, which are two separate programs:

Medicaid is a program funded by state and federal money. It is for people with low income who meet certain eligibility requirements and programs vary from state-to-state. The program mostly covers children, pregnant women, disabled adults, and seniors.
Medicare is a federal program for people who are age 65 or older, persons with a disability, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.

Medicaid

Applications for the Florida Medicaid Program are made through the Florida Department of Children and Families (DCF). For more information view the DCF website at www.myflorida.com/cf_web or call their toll-free number (866) 762-2237.

Information on Medicaid services can be found on the website for the Agency for Health Care Administration: http://ahca.MyFlorida.com (click Medicaid on the left hand side).

The Agency’s Area Offices have a list of doctors, dentists, and specialists who serve patients covered by Medicaid. They can also answer questions about Medicaid services and providers. To find the office that serves your area of the state, click http://ahca.MyFlorida.com. On the homepage click "Medicaid" then click “Area Offices.”

However, if you are in a Medicaid health plan you need to contact the health plan for a list of Medicaid providers. You can call the health plan customer service number listed on your card or other paperwork the health plan gave to you. If you do not have a number, or are uncertain what type of Medicaid coverage you have, you can contact the Area Office mentioned in the paragraph above.

General information on the Florida Medicaid Program can be found in the brochure, “Florida Medicaid – A Reference Guide.” To view the brochure click here or order it by calling the toll-free number (888) 419-3456.

Medicare

You can speak directly with Medicare by calling the toll-free number (800) 633-4227 or TTY (877) 486-2048 or to view the Medicare website, click www.Medicare.gov.

If you are eligible for Medicare, there are several choices you can make about your coverage. You can choose to remain in the Original Medicare Plan or enroll in a Medicare Advantage Plan. You might also choose to enroll in a Medicare Prescription Drug Plan. Following are descriptions of these various options.

1. The Original Medicare Plan

The Original Medicare Plan is a fee-for-service plan managed by the Federal Government. You are usually charged a fee for each health care service or supply you get. It includes Part A and Part B.

Medicare Part A helps cover inpatient care in hospitals, critical access hospitals, skilled nursing facilities (not custodial or long-term care), hospice care and some home health care. Certain conditions must be met to get these benefits. Most people automatically get Part A coverage without having to pay a monthly premium because they, or their spouses, paid Medicare taxes while working.

Medicare Part B helps cover doctors’ services; outpatient care; some preventive services like exams, lab tests, and shots to help prevent, find, or manage a medical condition; and other medical services that Part A doesn’t cover. Part B is optional and most people pay a monthly premium for Part B.

You will be covered by the Original Medicare Plan unless you join a Medicare Advantage Plan.

In addition, people in the Original Medicare Plan can choose to have Medicare Part D (described further down the page) and/or a Medigap policy (Medicare Supplement Insurance that is offered by private companies to help pay health care costs that the Original Medicare Plan doesn’t cover). To compare Medigap policies click www.Medicare.gov/MPPF.

2. Medicare Part C – Medicare Advantage Plans

Medicare Part C – Medicare Advantage Plans are run by private companies. They provide Part A (Hospital) and Part B (Medical) coverage. Some may also provide Part D (prescription drug) coverage. To join a Medicare Advantage Plan, you must live in the plan’s service area. The plan may have special rules that you need to follow like seeing doctors that belong to the plan or going to certain hospitals to get services. You may also have to pay a monthly premium for extra benefits. To compare Medicare Advantage Plans click www.Medicare.gov/MPPF.

3. Medicare Part D – Prescription Drug Benefit

Medicare Part D – Prescription Drug Benefit is provided through Medicare approved private health plans. Most people pay a monthly premium for this coverage though some plans don’t charge a premium. If you have Medicare, but not Medicaid, you can enroll in a Medicare Part D plan, but you are not required to do so.

If you are in a Medicare Advantage Plan (Part C) do not enroll in Medicare Part D. First speak with your Medicare Advantage Plan about your drug coverage. If you still have more questions, you might want to speak with a SHINE counselor. (The program is described further down this page.)

People with limited income and resources may qualify for extra help with prescription drug costs under Medicare Part D. To see if you qualify for this help contact the Social Security Administration’s toll-free number (800) 772-1213 or TTY (800) 325-0778, or view the website www.ssa.gov/prescriptionhelp. If you receive Medicaid, you automatically qualify for the extra help.

If you enroll in Medicare Part D you will want to compare these drug plans before you choose one – to see which ones cover the prescription medicines you take; how much coverage they offer; the cost of deductibles, co-payments and the monthly premium; and which pharmacies you can use with each plan. To learn more about Medicare Part D Prescription Drug Plans and to compare them, click www.Medicare.gov.

Medicaid and Medicare Can Work Together

If you are covered by both Medicare and Medicaid, the Florida Medicaid program may cover:

Your Medicare deductible (the amount you pay before Medicare starts to pay for covered services)
Part of your Medicare co-payment and co-insurance (the amount you pay for some covered services)
Premiums you pay for Medicare coverage (what you pay for Medicare)
Some services or items Medicare does not cover (up to the amount Medicaid will cover)

If you receive Medicare only, you may still be eligible to get help from Florida Medicaid to cover the above expenses. These benefits are offered through the following programs: Qualified Medicare Beneficiaries (QMB), Qualifying Individuals 1, and Special Low-Income Medicare Beneficiaries (SLMB). To apply for one of these programs or to receive more information, contact the Department of Children and Families’ toll-free number (866) 762-2237 or view their website www.myflorida.com/cf_web.

Private Insurance

If you are covered by private insurance, other than Medicare and Medicaid, talk with your health insurance provider and read the materials they give you to learn what your plan covers. If you have long-term care insurance, or are thinking about buying this type of insurance, find out exactly what it covers, under what conditions you can receive coverage, any restrictions that may apply, and what you need to do when coverage is needed.

The Florida Department of Financial Services (DFS) regulates insurance in Florida and provides consumer publications on health insurance, health maintenance organizations, long-term care insurance, and other types of insurance. You can also check to see if an insurance company or an insurance agent is licensed. For more information call the DFS toll-free number (800) 342-2762 or view their website www.fldfs.com.

SHINE Program

The SHINE Program (Serving Health Insurance Needs of Elders) at the Florida Department of Elder Affairs provides counseling to seniors on health insurance, including Medicaid, Medicare, Medicare Advantage Plans, Medigap, and Medicare Prescription Drug Plans. For more information view their website www.FloridaShine.org or call the toll-free number (800) 963-5337