I85PREP
⌘ K
HS 311 study materials
HS 311 study resources

HS 311: Medicare and Medicaid

HS 311 · Work through your exam, one topic at a time.

All guide sections

Medicare and Medicaid

Domain 7 tests the federal/state split: Medicare is federally funded and based on age or disability; Medicaid is jointly funded and income-based.

Medicare parts

  • Part A (hospital insurance): inpatient hospital, skilled nursing facility after a qualifying stay, hospice, and some home health. Funded by payroll tax; most people pay no premium. Coverage runs in benefit periods with a deductible and daily copays.
  • Part B (medical insurance): physician services, outpatient care, durable medical equipment, preventive services. Income-related premium; after the deductible, Medicare pays 80% of the approved amount and the beneficiary 20%, with no out-of-pocket maximum.
  • Part C (Medicare Advantage): private plans delivering Part A and B benefits, usually with networks and often with drug coverage.
  • Part D: outpatient prescription drug coverage through private plans, with standard benefit design and an annual out-of-pocket cap.
  • Medigap: standardized private supplemental policies (Plans A–N) that fill Part A/B cost sharing, with a six-month guaranteed-issue window at age 65 tied to Part B enrollment.

Eligibility: age 65 with 40 quarters of Medicare-taxed work (or a spouse's record); SSDI recipients after 24 months; people with ESRD or ALS qualify without the wait. The initial enrollment period spans seven months around the 65th birthday, and late Part B enrollment carries a permanent 10% penalty per 12-month period.

Medicaid

Jointly funded and state-administered, with mandatory and optional eligibility groups, MAGI-based income rules, long-term care for those meeting functional and financial tests (including spend-down), EPSDT for children, and dual-eligible beneficiaries who receive both programs. CHIP extends coverage to children above Medicaid thresholds.

Worked example

A beneficiary receives a Medicare-approved charge of $200 for a Part B service and has no Medigap.

  1. Assuming the Part B deductible is met, Medicare pays 80% = $160.
  2. The beneficiary owes 20% = $40, and because Part B has no out-of-pocket maximum, that 20% continues all year.

Traps

  • Assuming Medicare covers custodial long-term care.
  • Forgetting that Part B pays 80% with no cap.
  • Overlooking that the late-enrollment penalty is permanent.
  • Confusing Medicaid (income-based) with Medicare (age/disability) and misapplying Medigap guaranteed issue.