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different forms of government medical insurance......

What is the difference between Medicaid, Medicaid Waivers, EPSDT, and Medicare?

Medicaid is a federally subsidized health insurance program for low and moderate income persons. It is administered in New Mexico primarily through the Human Services Department. The federal government pays around 74% of Medicaid costs, and the state pays the rest. Medicaid covers most needed health care and there are no deductibles or co-pay.

There are several ways to be eligible for Medicaid. Generally, if you receive SSI benefits, you automatically qualify for Medicaid. Children in families whose income is less than 235% of the federal poverty level are likely to qualify and can usually be enrolled through their local schools or county health offices. Adults with very low incomes may qualify, and moderate income adults may qualify if they need the level of care provided in nursing homes.

Most people on Medicaid must receive their health care through one of the state's three managed care providers under the Salud! program: Cimarron, Lovelace, and Presbyterian. Each plan has its own network of hospitals, doctors, and other medical providers.

EPSDT (Early and Periodic Screening, Diagnosis and Treatment) is a Medicaid program which provides comprehensive services for children up to age 21. It covers all medically necessary services, including some services not usually covered by adult Medicaid, such as residential mental health treatment.

Medicaid waiver programs also provide services which are not usually covered by the regular Medicaid program (some of the Medicaid requirements are "waived" by request of the state). There are 4 waiver programs in New Mexico: the Developmental Disabilities (DD) waiver, the Disabled and Elderly (D&E) waiver, the Medically Fragile waiver, and the AIDS waiver. Each one uses Medicaid funds to provide services needed to support people in home or community settings rather than in facilities such as nursing homes. (See page 1 on the waiver waiting lists).

Medicare is the medical insurance most people are eligible for when they or their spouses retire. The insurance is administered by the Socail Security Administration, a federal government agency. People who have worked for a while and who become disabled and/or children whose working parent dies and who become eligible for SSDI are usually also eligible for Medicare. Medicare recipients usually have to pay 20% deductibles, their prescriptions are not covered, and they are limited as to what providers will give them for service. Some people may be both Medicaid and Medicare eligible. Some people on Medicare may be able to get additional support by applying for QMB(Qualifying Medicare Beneficiary), or SLMB/QI which can help with the cost of the premium coverage.