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Who’s eligible for Medicare, Medicaid, PeachCare? And how much does it cost them and taxpayers
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Dr. Alisa Davis prepares to meet with a patient Thursday, Nov. 14, 2019, at The Longstreet Clinic. - photo by Scott Rogers

Most residents in the Gainesville area, 46%, are insured through employer-sponsored health coverage. But another 15% rely on Medicare and 14% on Medicaid. 

Those numbers reflect the primary service area of the Northeast Georgia Health System, which includes Gainesville, Gillsville, Lula, Clermont and Murrayville ZIP codes, and is reported in the 2019 Community Health Needs Assessment of Northeast Georgia.

Of those who actually visited the hospital in 2018, 49.75% of those were Medicare patients, 13.7% were Medicaid, 28.3% used third-party insurance and 8.25% were self-pay.

Medicare and Medicaid serve distinct groups and can be controversial.

Here’s a few basics to understand both plans as well as PeachCare for Kids, which started in 1999 and is Georgia’s version of the Children’s Health Insurance Program.

Medicare 

Who: For those 65 or older, younger people with disabilities and people with end-stage renal disease.

What: A federal health insurance program that provides coverage including inpatient hospital stays, care in a skilled nursing facility up to 100 days, hospice care and some home health care along with certain doctors' services, outpatient care, medical supplies and preventive services.

Prescription drug coverage is an optional benefit offered to everyone who has Medicare. Those who decide not to get Medicare drug coverage when they’re first eligible may have to pay a late enrollment penalty.

Medicare Advantage, commonly known as Part C, is a plan that bundles hospital and medical coverage, and in some cases, drug coverage, and is run by Medicare-approved private insurers.

And then there’s private supplemental insurance, or Medigap, which pays for coverage not picked up by Medicare. Medigap plans, which are sold by private companies, don't cover long-term care, vision or dental care, hearing aids or eyeglasses.

How much it costs users:

  • Premiums for Part A, which covers inpatient hospital care, limited time in a skilled nursing care facility, limited home health care services and hospice care, are free for those who have paid Medicare taxes while working at least 10 years. Otherwise, they will be as high as $458 per month in 2020.

  • Part B, or medical insurance, covering doctor’s visits, outpatient care, medical supplies and preventive services, is $135.50 per month. You can get both when you sign up for Medicare or you can put off Part B if you’re still working and have health insurance through your employer. However, there’s a penalty for not signing up for Part B when you turn 65, so make sure you won’t be assessed a fee if you don’t sign up. Your monthly premium for Part B may go up 10% of the standard premium for each full 12-month period that you could have had Part B.

  • Part C and Part D premiums vary according to Medicare-approved private insurers’ plans.

How much it costs taxpayers: In 2018, it cost $582 billion, representing 14% of total federal spending, according to the Peter J. Peterson Foundation, a nonpartisan economic watchdog group.

Medicaid

Who: In Georgia, uninsured pregnant women, children, retirees age 65 and older, people who are legally blind or disabled. Those who need nursing home care or who have breast or cervical cancer may also qualify. Income guidelines also must be met. In general, if your household income is at or below 133% of the federal poverty line for your household size, your family is likely to be eligible for Medicaid. The poverty line for a family of four is $25,750.

What: A joint federal and state program that covers prescriptions, doctor visits, inpatient and outpatient hospital care, lab tests, X-rays, home health care, hospice care, medical equipment and supplies, non-emergency medical transportation services and dental care for those up to 21. Medicaid also offers benefits not normally covered by Medicare, like nursing home care after 100 days.

When applicants are approved for Medicaid, they are given the choice of health plans as part of Georgia Families: Amerigroup Community Care, CareSource, Peach State Health Plan and WellCare.

“If you have Medicare and full Medicaid coverage, most of your health care costs are likely covered,” according to Medicaid.

For those with both plans, Medicaid pays for services covered in part by Medicare, employer group health plans, and/or Medigap.

What could change: Georgia Gov. Brian Kemp is seeking a waiver request from the federal government so the state can partially expand the program. He is proposing uninsured adults in Georgia who make no more than the federal poverty level would qualify for Medicaid assistance if they spent at least 80 hours a month working, volunteering, training or studying. They would also have to pay monthly premiums.

Georgia is one of 14 states that have not fully expanded Medicaid under the Affordable Care Act. Kemp’s office has said full expansion would cost Georgia taxpayers more than $1.5 billion in the first five years.

How much it costs users: Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. You cannot be denied service because you are not able to pay the co-payment. However, your provider may bill you for the co-payment amount.

How much it costs taxpayers: Medicaid spending hit $592.2 billion in 2017, with federal expenditures accounting for $370.6 billion. 


PeachCare for Kids

Who: Children under 19 who do not qualify for Medicaid and live in households with incomes at or below 235% of the federal poverty level and who are U.S. citizens or qualified legal residents. The maximum income for a family of three is $50,126 and goes up roughly $10,000 for each additional child, according to benefits.gov. PeachCare is Georgia’s Children’s Health Insurance Program, which is in all states. 

What: A joint federal and state program that covers sick visits to the doctor; preventive services, such as immunizations and regular check-ups; specialist care; dental care; vision care, including vision screenings and eyeglasses; hospitalization; emergency room services; prescription medications; and mental health care.

How much it costs users: Free for families with children under 5. Otherwise, it’s $11 to $36 per month for one child and $16 to $72 for two or more children living in the same household, depending on family income. Income amounts are based on 247% of the federal poverty guidelines and are updated annually. 

How much it costs taxpayers: In fiscal 2016, CHIP spending totaled $15.6 billion, 92.5% paid by the federal government and 7.5% by the states and territories, according to the Medicaid and CHIP Payment and Access Commission.

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