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Medicaid versus Medicare

Dee Adams Nikjeh, PhD, CCC-SLP, ASHA Fellow

March 26, 2021

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Question

What is the difference between Medicaid and Medicare? 

Answer

Many, many people confuse Medicaid and Medicare.  In order to make it as simple as possible, consider the following information:

  • Medicaid is an assistance program that covers low- and no-income families and individuals
  • 2019 served 75+ million Americans (35+ million children)
  • Medicare is an insurance program that primarily covers seniors age 65 and older and disabled individuals who qualify for Social Security
  • 2019 served 64 million Americans
  • 2019 34% of Medicare-enrolled in Medicare Advantage plans
  • Some may be eligible for both, depending on circumstances

First, Medicaid and Medicare are both government-sponsored healthcare programs. However, think of Medicaid as "medical aid". It is an assistance program that covers low and no-income families and individuals. Medicare is "medical care". It is an insurance program that primarily covers seniors over the age of 65. In 2019, we had over 75 million Americans on Medicaid and 35 or more million of those people were children. In 2019, we had 64 million Americans that were on Medicare, about 34% of those are now enrolled in the Medicare Advantage Plans, and that number is increasing. It seems that every year the percentage of people in Medicare Advantage Plans is increasing.

Also, remember that because Medicaid and Medicare are two different types of government programs, some individuals may be eligible for both programs depending on their circumstances. So don't be surprised if they come into your office and when you ask for insurance, they give you a Medicaid card and a Medicare card.

Below is a list of resources that cover all of the information reviewed above. Follow the link listed to look for your MAC and LCDs in your area.

  • Check with your state Medicaid agency for a fee schedule and provider manuals
  • ASHA Medicare Information: www.asha.org/practice/reimbursement/Medicare/ 
  • ASHA Medicaid Tool Kit: www.asha.org/Practice/reimbursement/medicaid/Medicaid-Toolkit/
  • Affordable Care Act: www.medicaid.gov/AffordableCareAct/Provisions/Eligibility.html
  • 2018 Medicare and Medicaid Basics:  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ProgramBasicsText-Only.pdf
  • ASHA Model Superbill: https://www.asha.org/Practice/reimbursement/coding/Superbill-Templates-for-Audiologists-and-Speech-Language-Pathologists/
  • Local Coverage Determination: https://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx
  • Medicare Administrative Contractors:  https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List
  • 2020 Medicare Costs: https://www.medicare.gov/Pubs/pdf/11579-medicare-costs.pdf

Refer to the SpeechPathology.com course, Payment for SLP Services: Navigating Payer Sources, Payment Systems, & Practice Settings, for more information on accurate payment for SLP services. 


dee adams nikjeh

Dee Adams Nikjeh, PhD, CCC-SLP, ASHA Fellow

Dee Adams Nikjeh, PhD, CCC-SLP, ASHA Fellow, is an expert in health care coding systems, compliance requirements, and billing practices for the field of speech-language pathology. She co-chairs ASHA's Health Care Economics Committee and the American Medical Association's Relative Value Update Committee/Health Care Professionals Advisory Committee and is an Expert Witness in the field of speech-language pathology for the United States Department of Justice Civil Division-Fraud Section. Dr. Nikjeh's professional career in the field of communication sciences and disorders spans four decades as a clinician, supervisor, researcher, educator, mentor, consultant, and an advocate of the profession. She has served on ASHA's Legislative Council and the Executive Board of the Council of State Association Presidents. She is a past-president of the Florida Association of Speech-Language Pathologists and Audiologists.


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