Medicare vs. Medicaid: Defining coverage options in nny

Matthew Wiley of the Jefferson County Office of the Aging.

BY: Norah Machia

   It’s the federal government health insurance program initially started in 1966 through the Social Security Administration, but now administered through the Centers for Medicaid and Medicare Services.

  One way to distinguish this coverage from Medicaid is to remember it ends with the letter “e.” The coverage is primarily for the “elderly,” those 65 and older. Although there are a few exceptions.

    People of any age with certain disabilities, and those with end stage renal disease or amyotrophic lateral sclerosis (commonly referred to as “Lou Gehrig’s Disease”) may also qualify for Medicare coverage.

    The Medicare program is funded by a combination of payroll taxes, premiums and surtaxes paid by the beneficiaries themselves, along with general government revenue.

    In Jefferson County, the average reimbursement for medical costs per Medicare enrollee was $8,278 a year in 2016. That figure was $7,839 for enrollees in Lewis County and $8,439 for those in St. Lawrence County, according to

   But here is where things can get complicated – Medicare is not a single program, but is comprised of several plans.

     Part A is hospital insurance, Part B is medical insurance, and Part D covers most prescription drugs (although some may be covered in Part B, depending on whether they are self-administered).

     What happened to Part C?

     The Part C Health Plans are also called Medicare Advantage Plans, which are an alternative and popular way for people to receive the benefits of Parts A, B, and D in one plan. The Medicare Advantage plans pay for managed health care based on monthly fees, as opposed to a fee-for service billing system. Most of these plans are administered as health maintenance organizations (HMOs), or Preferred Provider Organizations (PPOs).

   In most cases, Medicare does not cover all the health care expenses of an individual. Those who are enrolled in the Medicare program cover the remaining health costs through several options.

   Some low-income recipients may be dually enrolled in Medicare and Medicaid. Others have their own additional insurance through retirement plans, while some pay “out of pocket” for their expenses not covered by Medicare.

  But for many people, a popular option is to purchase a supplemental insurance policy to help pay the uncovered expenses (referred to as “Medigap” policies). There are numerous supplemental insurance options available to north country residents and deciding the best one can be quite a challenge.

    That’s why there are counselors available in the Offices for the Aging in Jefferson, Lewis and St. Lawrence counties to help people figure out the best Medicare products for their situation. The counseling is offered free of charge. 

     If you start collecting Social Security benefits at age 65, you are automatically enrolled in the Medicare program, explained Matthew Wiley, a HICAP Coordinator for the Jefferson County Office for the Aging.

     His title stands for “Health Insurance Information, Counseling, and Assistance Program,” a statewide initiative to help seniors citizens weave their way through the large maze of options available for Medicare and supplemental insurance plans.

    There are many regulations to each program, including specific enrollment periods, exceptions for certain medical conditions, income guidelines to pay for premiums, etc. The list is endless.

     “A person on Medicare can choose from many options,” said Mr. Wiley. For example, there are five companies administering Medicare Advantage programs and about 10 companies offering supplemental insurance programs in Jefferson County.

   In New York state, there is an additional state-funded program called EPIC (Elderly Pharmaceutical Insurance Coverage), a program that helps older adults on Medicare pay for prescription drug costs by supplementing their existing Medicare drug coverage.

     While it all may seem overwhelming, there is help available at the Offices for the Aging throughout the north country.

     These offices have specially trained counselors to assist residents 60 years of age and older in learning about the different health insurance options through Medicare, the supplemental insurance policies (Medigap policies), the Medicare Advantage Plans and prescription drug plans.

     “We can meet with senior citizens in our office and often take care of the actual enrollment process here,” said Mr. Wiley.

     For more information, contact the Offices of the Aging in these counties: Jefferson, 315-785-3191, St. Lawrence, 315-386-4730, or Lewis 315-376-5313.