Medicare and Medicaid are separate programs whose respective enrollment processes puzzle millions of Americans, which can be especially challenging for those who qualify for both at the same time. The two programs cover many of the same services, but Medicare pays first for the Medicare-covered services that are also covered by Medicaid. Medicaid covers services that Medicare does not cover.

Since their joint implementation in 1965, Medicare and Medicaid have completely transformed the healthcare landscape in the United States. But the differences between the two are significant. Medicaid is managed by states and its eligibility is based on income. It was built to provide healthcare coverage to people with lower incomes, families and children, pregnant women, the elderly, and people with disabilities. Its current enrollment is at 85 million Americans. 

Medicare, a federal program reserved for older Americans and those with disabilities, boasts 65 million beneficiaries today – 18.5% of the U.S. population. From this group of Americans some 26 million (42% of the Medicare population) are now enrolled in Medicare Advantage, which is offered by Medicare-approved private companies that must follow rules set by Medicare and offer an alternative to Original Medicare. 

Medicaid and Medicare converge on an often-overlooked front: Dual Eligible Special Needs Plans, or D-SNPs. These special plans, which are types of Medicare Advantage, go beyond Medicaid and original Medicare alone. Individuals of any age who qualify for both Medicare and Medicaid qualify for D-SNPs, and the type of plan a dual-eligible can enroll in depends on their existing Medicaid category.

The dual-eligible population falls into two groups—“partial duals” and “full duals”—depending on the level of Medicaid benefits for which an individual is eligible. 

Partial duals are so called because Medicaid pays some of the expenses they incur under Medicare. These expenses include the premiums for Part B and for Part A, if applicable. Medicaid may also pay for some other cost-sharing amounts owed under Medicare, such as deductibles, coinsurance, and copayments.

In addition to the benefits to which partial duals are entitled, full duals are entitled to Medicaid coverage for various health care services that Medicare does not cover, such as most types of long-term services and support. Duals with lower income and asset levels fall into the full duals category and receive the full Medicaid benefits that their state offers.

This is a big conversation – approximately 9.2 million people nationwide are qualified for dual-eligible status. But according to CMS, only 3.8 million beneficiaries were enrolled as of early 2022. For these millions of Americans, trying to configure health care needs with both Medicare and Medicaid services can be doubly challenging.

At Hella Health, we deploy technology to simplify the task of selecting a Medicare plan from the myriad of options. We can help dual-eligibles with D-SNP enrollment, guiding them towards a D-SNP plan that fits their needs. 

Whether it be Medicare, Medicaid, or integrated, landing on the right plan can be vital. But unfortunately, many older Americans do not have the tools at their disposal to make an informed decision that best suits their individual healthcare needs. 

This is exactly why we started Hella Health – technology can make the choice easy.

•June 13, 2022