Statutory Health Insurance (Gesetzliche Krankenversicherung, GKV)
Long-term care: According to the law, people are eligible to claim benefits from the LTCI if they are in need of care because of an illness or disability. In general, there are three different arrangements a recipient can choose from: care allowance, home care (in kind), and residential care. The definition of"in need of care" is fundamental for eligibility and the level of benefits received.
Assessment of the need for long-term care and classification into a care grade (see Table) are performed using an assessment instrument that takes a person’s individual care situation as its starting point and is based on questions such as what the person in need of nursing care can manage to do in everyday life, what abilities they still have, how independent they are and what activities they need help with. In 2017, eligibility categories were simplified into five care levels.
In general, Medicare is available for people age 65 or older, younger people with disabilities and people with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant). To be eligible for any Medicare benefits, these individuals must 1) be lawful permanent residents (LPR, holding a green card) and 2) have five years of continuous residence in the United States immediately prior to Medicare enrollment. For details, see Table. People with disabilities under 65 may also be eligible if they receive SSDI. Specific medical conditions may also help people become eligible to enroll in Medicare.
People qualify for Medicare coverage, and Medicare Part A premiums are entirely waived, if the following circumstances apply:
They are 65 years or older and US citizens or have been permanent legal residents for five continuous years, and they or their spouse (or qualifying ex-spouse) has paid Medicare taxes for at least 10 years; or
They are under 65, disabled, and have been receiving either Social Security SSDI benefits or Railroad Retirement Board disability benefits; they must receive one of these benefits for at least 24 months from date of entitlement (eligibility for first disability payment) before becoming eligible to enroll in Medicare; or
They get continuing dialysis for end-stage renal disease or need a kidney transplant.
Those who are 65 and older who choose to enroll in Part A Medicare must pay a monthly premium to remain enrolled in Medicare Part A if they or their spouse have not paid the qualifying Medicare payroll taxes.
People with disabilities who receive SSDI are eligible for Medicare while they continue to receive SSDI payments; they lose eligibility for Medicare based on disability if they stop receiving SSDI.
Medicaid (Means-tested system)
Mandatory eligibility groups include low-income children below a certain wage, pregnant women, parents of Medicaid-eligible children who meet certain income requirements, and low-income seniors (see Table, Table, Table, Table for details).
Disabled individuals with low incomes are covered by Medicaid. However, states are allowed to have different eligibility requirements than the SSI disability program. Whether SSI recipients are automatically eligible for and enrolled in Medicaid depends on the state that the recipient lives in (see Table, Table)
Note: Some beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those making below a certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), as well as some of their out of pocket medical and hospital expenses.