Medicare extends medical coverage and benefits to individuals aged 65 or older or those who meet specific disability criteria. Medicaid, on the other hand, is a program that provides assistance to people with low income and resources, helping them cover medical expenses. This program operates jointly under the guidance of both the federal and state governments. Additionally, Medicaid offers benefits that typically go beyond what is included in Medicare.
Gaining a deeper comprehension of your healthcare coverage entails understanding whether you qualify for these programs and how Medicare and Medicaid function in harmony. This knowledge proves invaluable in navigating the complexities of the healthcare system. By grasping the eligibility criteria for these programs, you can ascertain whether you meet the necessary requirements. Furthermore, comprehending how Medicare and Medicaid collaborate offers insights into the scope of your healthcare coverage
Medicare and Medicaid
Medicare and Medicaid differ significantly in their eligibility requirements. Medicaid eligibility is determined based on income, while Medicare is contingent on age or disability status. Individuals who qualify for both Medicare and Medicaid are often enrolled in a program that provides financial assistance for healthcare expenses. This program allocates funds to aid in covering medical costs, including hospital care, doctor visits, medical equipment, and outpatient services.
For those eligible for both Medicare and Medicaid, these programs work together to provide coverage in the following ways:
Financial Assistance: Individuals with both Medicare and Medicaid are typically automatically enrolled in a program that offers financial aid for healthcare expenses. Depending on individual circumstances, one may fall into different programs, such as:
- The Qualified Medicare Beneficiary (QMB) program, which assists with paying Medicare cost-sharing like deductibles, coinsurance, and copays for both Part A and Part B. Enrollment in this program is income-dependent, and it also automatically enrolls you in the Extra Help prescription drug program.
- The Specified Low-Income Medicare Beneficiary (SLMB) program, which helps with Part B premiums and includes automatic enrollment in Extra Help.
- The Qualifying Individual (QI) program, which aids with Part B premiums, but requires reapplication for benefits each year.
- The Qualified Disabled and Working Individuals (QDWI) program, designed for individuals with disabilities under age 65, which helps pay for Part A premiums.
Medicaid can also assist with paying for Medicare Part B premiums, Part B deductible, Part A deductible, copays, and coinsurance for Part A and Part B services.
Medicaid can assist in care coordination. In some states, individuals may be required to enroll in Medicaid private health plans or Medicaid Managed Care (MMC) plans. These plans may offer the option to join a Medicare Advantage plan, aiming to improve the coordination of care and effectively combine Medicare and Medicaid benefits.
Medicaid can provide coverage for services not included in Medicare. While Medicare generally covers most healthcare needs, there are certain services it does not cover. In such cases, Medicaid proves beneficial as it covers some of these additional services, including nursing home care, dental care, transportation, eyeglasses, physical therapy, and other services.
It is crucial to understand that becoming eligible for Medicare does not result in losing Medicaid eligibility. As long as your income meets the Medicaid eligibility requirements in your state, you can continue to receive both Medicare and Medicaid coverage.
Medicare and Medicaid Dual Eligibility
Some individuals may qualify for both Medicare based on age or disability and Medicaid based on income or other state requirements. When you have dual eligibility for both Medicare and Medicaid, most of your healthcare costs are likely to be covered, and you may not have to pay anything out-of-pocket.
With dual eligibility, you have the option to receive your Medicare coverage through Original Medicare or a Part C Medicare Advantage plan. Additionally, you will receive your Part D prescription drug benefits through Medicare, automatically qualifying for Extra Help to assist with your Part D coverage costs. However, it is essential to note that despite receiving Extra Help, you still need to select and enroll in a Part D drug plan.
Dual eligibility can fall into two categories:
- Full benefit dual eligible, which means you have comprehensive Medicaid coverage.
- Partial dual eligible, which means you will receive assistance with Medicare premiums and other cost-sharing.
Understanding Dual Health Plans
Dual health plans cater to individuals who are dual eligible and have both Medicare and Medicaid. These plans are a specific type of Part C (Medicare Advantage) plan that combines hospital, medical, and prescription drug coverage. In many cases, these plans have a $0 premium, making them a cost-effective choice.
Private insurance companies offer these dual health plans, allowing you to find one that best suits your coverage and healthcare needs.
Determining Dual Eligibility
Eligibility requirements for dual eligibility can vary from state to state, typically taking into account your income and financial assets. You can contact your state’s Medicaid office to determine if you qualify for both Medicare and Medicaid.
Generally, beneficiaries with earnings below 138% of the federal poverty level are eligible for both programs. Some states may have additional requirements, such as meeting a limited savings threshold. Seniors living in nursing homes are often dual eligible due to their age and financial circumstances.
Medicare or Medicaid as the Primary Insurer?
If you have both Medicare and Medicaid, Medicare takes precedence as the primary insurer and will be the first to pay for covered services. Medicaid, as the secondary insurer, will pay after Medicare, employer group health plans, and/or Medicare Supplement (Medigap) insurance have made their payments.
However, Medicaid can cover certain services that Medicare does not, such as nursing home care. In such cases, Medicaid would be the primary payer for those specific services, while Medicare remains the primary payer for any other Medicare-covered services received.
Additionally, Medicaid can help with other out-of-pocket expenses such as Medicare premiums, deductibles, and copays.
Need help? Call Brady Insurance Marketing: 801-347-2087. Our assistance is at no cost to you