Senior solutions: how to secure both Medicare and Medicaid?

You may have put in a lot of effort throughout your life to earn a good retirement, but even the best-laid plans can go awry. And while Medicare is there to help cover increasing medical costs, there are still a lot of gaps that can leave older Americans struggling to make ends meet. That’s where Medicaid comes in. Have you ever wondered whether you could receive Medicaid as well as Medicare? Here’s how!

How do Medicare and Medicaid work together?

Approximately 20% of Medicare beneficiaries are dual eligibles – people who are able to receive Medicaid benefits as well as Medicare (about 12.3 million beneficiaries). In this scenario, Medicare functions as the primary payer of services covered by Medicaid, including doctors’ visits, hospital care, and home healthcare. In addition to Medicare, Medicaid provides secondary coverage for services that Medicare provides, including physician services, hospitalizations, home health care, and nursing home care. Medicaid always pays last, so it is always the payer last in line. Medicare pays first for medical visits made to a provider who accepts both insurance plans. After that, Medicaid covers Medicare coinsurance and copayments.

Another way Medicare with Medicaid work together is through the different  Medicare Savings Programs (MSPs) are a subset of Medicaid benefits that assist paying for Medicare costs. These programs help those qualified to afford Medicare. These are the four different MSPs, and each has different income and resource eligibility limits:

• Qualified Medicare Beneficiary (QMB) Program
• Specified Low-Income Medicare Beneficiary (SLMB) Program
• Qualifying Individual (QI) Program
• Qualified Disabled and Working Individuals (QDWI) Program

Typically, if you qualify for the QMB program, SLMB, or QI program, meaning you use Medicare with Medicaid, you automatically qualify to also get Extra Help paying for Medicare drug coverage.

In some states, you may also have the option of enrolling in a private Medicaid health plan, commonly known as Medicaid Managed Care (MMC). Further, Medicare Advantage Plans may be offered as options that coordinate using Medicare with Medicaid coverage.

Who is qualified to receive Medicare and Medicaid?

The federal government governs Medicare eligibility, which is universal across the country. However, the states administer both Medicaid and MSPs (each under a federally regulated framework), for which the income limits differ considerably between states. 

The Centers for Medicare and Medicaid Services (CMS) offers a directory of Medicaid agencies.

You can contact the Medicaid office in your state to find out whether you are eligible for Medicaid. A web search for the Medicaid offices in one’s region will lead to contact information – but beneficiaries should ensure that the message comes from the appropriate government agency before providing any personal information.

How can I apply for dual eligible Medicare and Medicaid?

Is it possible for you to receive coverage for Medicaid on top of Medicare? Depending on the following factors, you may meet the requirements for the dual-eligible plan if:

• You are eligible under your state’s Medicaid program
• You are eligible for Medicare Parts A and B (Original Medicare)
• You live in the dual-eligible plan’s coverage area

Most nursing home residents have dual eligibility: Medicare is available to those over 65, while Medicaid is available based on their financial circumstances. Another typical scenario is for Medicare recipients under 65 who receive disability benefits to have access to Medicaid services. 

Additionally, dual-eligible individuals are classified according to whether they receive Medicaid partial or full coverage.

While full-benefit dual eligibles receive complete Medicaid coverage, partial benefit dual-eligibles benefit from assistance with Medicare’s costs through their enrollment in an MSP. As a result, some recipients have Medicaid, Medicare, and an MSP.

Is there a Special Enrollment Period for Medicare dual eligibility?

If you are eligible for both Medicare and Medicaid, you can join, switch, or drop your Medicare Advantage Plan or Medicare prescription drug coverage one time during each of these periods:

• January–March
• April–June
• July–September

If you make a change, it will take effect on the first day of the following month. You’ll have to wait for the next period to make another change. But, you can’t use this Special Enrollment Period from October–December. 

During Annual Open Enrollment (October 15–December 7), everyone with Medicare plans can make changes to their coverage, and the changes will take effect on January 1.

How much income are dual-eligible beneficiaries expect to earn?

If the beneficiary earns no more than 135% of the federal poverty limit and has little savings (while some states do not require assets’ low levels), they may qualify for the MSP. This amounts to $17,226 a year for single beneficiaries, while for married couples, it’s $23,274. Those with income and assets even lower than the Medicaid eligibility limits are able to obtain full Medicaid benefits (though the amount is different from state to state).

Medicaid and Medicare are both available to me. What is the reimbursement process?

When dual-eligible Medicare and Medicaid beneficiaries have medical costs, Medicare becomes the primary payer and pays first, with Medicaid paying second, always paying last. However, there are certain things that Medicare doesn’t cover, such as long-term care. If a beneficiary has a skilled need for long-term care services, which Medicaid primarily covers, Medicare will remain the primary health insurance carrier for services rendered in the long-term-care facility, such as nursing care and physical therapy.

In rare cases, if a dual-eligible Medicare and Medicaid beneficiary has supplementary benefits (such as a Medigap plan), Medicare is the largest payer, Medigap becomes the next payer, and Medicaid, which always pays last, will be the tertiary payer.

Putting it all together

There are several things savvy older Americans need to consider when it’s time to determine their eligibility for free health care programs such as Medicaid. While it’s completely possible to receive Medicare and Medicaid coverage simultaneously, it’s crucial to educate yourself and become familiar with what each program offers to make an informed selection about which is best for you. 

In addition, it is imperative to remember that if you are dual-eligible for Medicare and Medicaid, it is up to you to determine what best meets your needs. Don’t forget that you can join, switch, or drop your Medicare Advantage Plan or Medicare prescription drug coverage one time during each of these periods: January–March, April–June, and July–September. This can give you the peace of mind of knowing that you’re covered no matter what life throws your way. And remember, if you need to learn more about your Medicare choices, you can visit Hellahealth to learn more.