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Overview of Health Care Coverage for Older People

By

Roger I. Schreck

, MD

Last full review/revision Feb 2020| Content last modified Feb 2020
Click here for the Professional Version
NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
Topic Resources

Current details regarding funding and availability of medical care in the United States remain unsettled. The reader is referred to the Centers for Medicare & Medicaid Services and The Henry J. Kaiser Family Foundation for recent information.

Dealing with the costs of a serious or chronic disorder can be as distressing as dealing with the disorder itself. The costs are often beyond the personal resources of most people. For older people in the United States, most health care expenses are paid for by the following:

  • Medicare: It helps people who are age 65 or older, who are disabled, who are on kidney dialysis, or who have amyotrophic lateral sclerosis.

  • Medicaid: It helps certain people who are poor or disabled.

  • Other government programs such as the Department of Veterans Affairs (VA): The VA provides health care for honorably discharged veterans who meet certain eligibility requirements.

  • Private insurance

  • Out-of-pocket payments

In addition, many states offer health-related benefits and programs for older people, such as subsidies for transportation, housing, utilities, telephone, and food expenses, as well as help at home and nutrition services.

Understanding how Medicare, Medicaid, or other government programs work is complicated. What is completely paid for, what is partly paid for, who pays for how much of what, and how the payments are arranged can be difficult to understand. The programs change frequently, and for Medicaid, the regulations vary from state to state. But part of the problem is the complexity and fragmented nature of the U.S. health care system and of the payment system for health care.

Health care can be paid for in two ways (see Financial Issues in Health Care):

  • Fee-for-service: Health care practitioners and institutions are paid for each hospital stay, each visit to a practitioner, each test, and each treatment.

  • Capitation: Practitioners and institutions are paid a fixed amount each month for each person regardless of how many or few visits, tests, or procedures the person has.

Some health care plans are managed. Managed care simply means that a health care plan gives directions to health care practitioners and institutions about what care should be provided and when. These directions are intended to help ensure better, more consistent care and to control costs. Managed care can include health maintenance organizations (HMOs), preferred provider organizations (PPOs), point-of-service (POS) plans, or a combination.

Table
icon

Who Pays for What?

Type of Care

Services

Covered by

Hospital care*

Inpatient care, including mental health care

General nursing and other hospital services and supplies

Drugs used during hospitalization

A semiprivate room (a private room only if medically necessary)

Meals

Medicare Part A

Medicare Part C (Medicare Advantage)

Medicaid

Department of Veterans Affairs (VA)†

Short-term care in a certified skilled nursing facility (nursing home)

Skilled nursing care

Social services

Drugs used in the facility

Medical supplies and equipment used in the facility

Dietary counseling

Physical, occupational, and speech therapy (if needed) to meet the person's health goals

Transportation by ambulance (when other transportation endangers health) to the nearest facility providing needed services unavailable at the skilled nursing facility

A semiprivate room

Meals

Medicare Part A if people need short-term care temporarily after a hospital stay

Medicare Part C if people need short-term care temporarily after a hospital stay

Medicaid

VA†

Outpatient care

Doctor’s, nurse practitioner’s, and physician assistant’s fees, including for certain telehealth services (real-time remote office visits and consultations) 

Emergency department visits

Transportation by ambulance (when other transportation endangers health)

Outpatient surgery (with no overnight stay in the hospital)

Rehabilitation (physical, occupational, and speech therapy)

Diagnostic tests, such as x-rays and laboratory tests

Outpatient mental health care

Outpatient dialysis

A second opinion if surgery is recommended and a third opinion if opinions differ

For people with diabetes, diabetes supplies, self-management training, eye examinations, and nutrition counseling

Smoking cessation

Durable medical equipment, such as wheelchairs, hospital beds, oxygen, and walkers

Medicare Part B

Medicare Part C

Medicaid

VA†

Home health care

Personal care, including help with eating, bathing, going to the bathroom, dressing

Part-time skilled nursing care

Physical, occupational, and speech therapy

Home health aide services

Social services

Medical supplies, such as wound dressings, but not prescription drugs

Medicare Part A if people are homebound and need part-time skilled nursing care or rehabilitation on a daily basis

Medicare Part B

Medicare Part C

Medicaid

VA†

Preventive care

Screening tests for breast, cervical, colorectal, lung, prostate, and vaginal cancer

Screening tests for abdominal aortic aneurysm, depression, hepatitis B and C, HIV, elevated cholesterol 

Screening and counseling for alcohol misuse, cardiovascular disease, diabetes, obesity, sexually transmitted infections, tobacco use

Bone density measurements

Glaucoma tests

Influenza, pneumococcal, and hepatitis B vaccinations

One-time Welcome-to-Medicare preventive visit

Yearly wellness visit (includes voluntary advance care directive preparation)

Nutrition therapy services

Medicare Part B

Medicare Part C

Medicaid

VA†

Extra benefits

Prescription drugs

Eyeglasses

Hearing aids

Medicare Part C

Medicare Part D (prescription drug plans)

Medicare Part B (limited outpatient prescription drugs)

Medicaid in some states

VA†

Long-term care in an assisted living community

Varies greatly from community to community

Meals

Help with daily activities

Some social and recreational activities

Some health care

Medicaid in a few states (partial coverage)

VA† in some situations

Long-term care in a skilled nursing facility (nursing home)

Varies from state to state

Medicaid

VA†

Hospice care

Physical care and counseling

Room and meals only during inpatient respite care and short-term hospital stays

Medicare Part A

Medicare Part C

* Medicare Part A covers care in long-term care hospitals for people who may have more than one serious condition and be expected to improve and return home.

† For the Veterans Administration (VA), the rules of eligibility vary for different services and change frequently.

More Information

NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
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