How To Qualify For Both Medicare And Medicaid

How Do I Know If I Qualify For Medicaid And Medicare

Dual Eligibility: Choice and Access for Individuals Eligible for Medicare and Medicaid, Judy Feder

Twelve million individuals are currently enrolled in both Medicaid and Medicare.1 These individuals are known as dual eligible beneficiaries because they qualify for both programs. As long as you meet the federal qualifications for Medicare eligibility and the state-specific qualifications for Medicaid eligibility, you will qualify as a dual eligible. To qualify for Medicare, individuals generally need to be 65 or older or have a qualifying disability.

There are several levels of assistance an individual can receive as a dual eligible beneficiary. The term full dual eligible refers to individuals who are enrolled in Medicare and receive full Medicaid benefits. Individuals who receive assistance from Medicaid to pay for Medicare premiums or cost sharing* are known as partial dual eligible.

*Cost sharing is the amount of your health care that you pay out of your own pocket. Typically, this includes deductibles, coinsurance, and copayments.

Medicare Vs Medicaid: Whats The Difference

There are a few main distinctions between Medicare and Medicaid.

Medicaid

Medicaid is a health insurance program that provides financial assistance to low-income individuals or families or families with limited financial resources.

While individual states are responsible for running the Medicaid program, the federal government creates the rules and regulations that govern it.

Medicaid is available to people of all ages and gender identities. Children, families, pregnant women, persons with disabilities, and the elderly may all be eligible for Medicaid coverage under certain conditions.

Medicare

Medicare is a health insurance program that provides coverage to people 65 and older and those with certain medical conditions, including those who have any disability.

A person must meet eligibility standards based on their own or their spouses job history. They may be eligible for free hospitalization but must pay a premium for medical and prescription drug coverage.

To be eligible for Medicare, a person does not need to meet income-related criteria.

Medicare Ineligibility

The Medicare eligibility requirement is that you must be 65 years old or older. Suppose you or your spouse are 65 years old or older and have paid enough Medicare taxes through previous employment. In that case, you or your spouse may be eligible for premium-free Part A of the Medicare program .

They may also be eligible for Medicare Part B, covering doctor visits and other medical expenses.

The Majority Of The Public Holds Favorable Views Of Medicaid

Public opinion polling suggests that Medicaid has broad support. Seven in ten Americans say they have ever had a connection with Medicaid including three in ten who were ever covered themselves. Even across political parties, majorities have a favorable opinion of Medicaid and say that the program is working well . In addition, polling shows that few Americans want decreases in federal Medicaid funding. In addition to broad-based support, Medicaid has very strong support among those who are disproportionately served by Medicaid including children with special health care needs, seniors, and people with disabilities.

Figure 10: Large Shares Across Parties Say They Have a Favorable Opinion of Medicaid

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What To Do If You Dont Qualify For Medicaid

If you dont qualify for Medicaid, you can possibly get subsidized health care through the Obamacare marketplaces during a special enrollment or open enrollment period. Americans who making more than 100% of the FPL qualify for a premium tax credit that can significantly lower the cost of a plan.

Federal open enrollment for 2022 health care plans runs until Jan. 15, 2022, though some state exchanges are open longer. Learn 2022 open enrollments dates by state. Healthcare.gov, the federal exchange, usually opens from November 1 to December 15 each year.

If you cant find affordable health care on your marketplace during open enrollment, you have a few back-up options.

These include:

Short-term health insurance: Originally designed to prevent short-term health insurance gaps, these plans are cheaper, but much less comprehensive than traditional coverage. They dont have to cover Obamacares 10 essential benefits or pre-existing conditions. Following changes by the Trump administration, short-term health plans can last from three months to potentially three years, though som estates have stricter limits.

Limited benefit plans: These plans cover a very small portion of the costs associated with certain medical events, like a doctors visit or ambulance ride. Both the number of events and dollar amounts covered are capped.

Prescription discount cards: While these cards wont help you pay for inpatient or outpatient care, they do help you get medication at discounted rates.

What Might Medicaid Pay For That Medicare Doesnt

strategicbusinessdesigns: Medicare Eligibility California

The premium for Medicare Part B, which covers doctor visits and other outpatient services. That monthly premium will be $164.90 in 2023.

The Medicare Part B deductible, which will be $226 for 2023.

The Medicare Part A deductible, which for 2023 will be $1,600 for hospital stays.

Both Medicare Part A and Part B copays and coinsurance.

The Medicare Part D premium, deductibles and copays for prescription drugs. Coverage for those costs is available through the Extra Help program, which Medicaid and Medicare Savings Program enrollees automatically qualify for.

Nursing home care and home- and community-based long-term services and supports.

In some states, Medicaid will cover benefits that Medicare does not, such as dental care, transportation to and from doctor visits, eyeglasses, physical therapy and other services.

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Medicaid Vs Medicare: You Can Have Both

Posted: January 17, 2020

Medicaid and Medicare. Its hard to think of two words that cause as much confusion.

What is the difference between the Medicare and Medicaid programs?
What exactly are Medicaid and Medicare?

Whos eligible to get Medicaid or to get Medicare?
How can you have Medicare and Medicaid at the same time?

Read on to find out the answers to these questions and more.

A And B Financial Help

Once youâre dual eligible, youll be able to use your Medicaid to pay some or all of your Original Medicare premiums and health care costs.

But just remember that the type of benefit status you have as a dual eligible will affect how you can use your Medicaid to cover your Medicare.

With some dual-eligible benefit types, you will only be able to use your Medicaid insurance to pay for one part of Medicare .

With other dual-eligible types, youâll be able to cover the entire cost of enrolling in Medicare. In these cases, Medicaid will pay your Medicare premiums, your deductibles, and your coinsurance amounts.

Key Facts about Dual Eligibles in the U.S.

In 2020, there were 12.3 million dually eligible beneficiaries enrolled in Medicare and Medicaid.
Dual eligibles account for around 20% of all Medicare enrollees and 15% of Medicare enrollees.

In 2019, Wyoming had the lowest number of dual eligibles , and California had the highest .

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Medicaid Reimbursement Rates In 2022

Although the Medicaid reimbursement rates are low, they vary according to State. Usually, Medicaid pays providers 72% of total Medicare rates. Since the payment is low, physicians are reluctant to participate in a Medicaid program.

The State pays providers on a fee-for-service model agreement. However, Medicaid providers are also shifting to a Value-based model where fees charge according to the person. Furthermore, you dont have to worry about filing claims because the State is responsible for reimbursing payments to the provider.

Dual Eligibility For Medicare And Medicaid: What It Means For You

What Are Dual Special Needs Plans (D-SNP)?

The distinction between Medicare and Medicaid can be confusing. Because they sometimes both apply, it is important to have a firm understanding of both. Medicare and Medicaid dual eligibility can play a very important role in the services that you â or your loved one â receives, and having the professional legal counsel of an experienced Florida Medicaid planning attorney in your corner is paramount.

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What Are The Qualifications For Medicaid

Medicaid beneficiaries generally must be residents of the state in which they are receiving Medicaid. They must be either citizens of the United States or certain qualified non-citizens, such as lawful permanent residents. In addition, some eligibility groups are limited by age, or by pregnancy or parenting status.

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Qualified Medicare Beneficiary Program

This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance and copayments.

Eligibility requires:

Income of no more than $1,094 per month for an individual in 2021, or $1,472 per month for a married couple

Resources of no more than $7,970 for an individual in 2021, or $11,960 for a married couple

How Medicare And Medicaid Work Together

Medicaid administers a set of programs called Medicare Savings Programs or MSPs. These are specifically for individuals who are enrolled in Medicare and have limited income and resources. There are four different MSPs, each with varying levels of eligibility thresholds.

Qualified Medicare Beneficiary : This level will pay for Medicare Part A and B monthly premiums, and individuals will not be billed for Medicare-approved services. Beneficiaries must see Medicare providers to receive this benefit.

Specified Low-Income Medicare Beneficiary : This level will pay the Medicare Part B premium.

Qualifying Individual : This level will also pay the Part B premium.

Qualified Disabled Working Individual : This level pays for the Part A premium. To qualify for QDWI, you must be under the age of 65, be employed, have a disabling impairment, have limited income, and not already be eligible for Medicaid.

If you are eligible for both Medicare and Medicaid, youll receive more financial assistance to help pay for your healthcare needs. Depending on your level of eligibility, Medicaid may help pay for your Medicare Part B premium, deductibles, copayments, and coinsurance. It will also pay the Medicare Part A premium, but most beneficiaries enjoy premium-free Part A.

Medicare will remain the primary payor, and Medicaid will be secondary. Beneficiaries can still choose if theyd like to continue with Original Medicare or enroll in a Medicare Advantage plan.

Who Can Qualify For Both Medicare And Medicaid

People who are dual-eligible for Medicare and Medicaid are referred to as dual-eligible beneficiaries. Moreover, each state determines Medicaid coverage, and as a result, Medicaid benefits may differ.

Receiving both Medicare and Medicaid can assist in lowering healthcare expenditures for individuals who are in need.

According to general practice, Medicare pays for healthcare services first, with Medicaid covering any existing gaps up to Medicaids payment flexibility limits.

According to an article in the journal Health Affairs, an estimated two-thirds of those who are dual-eligible meet the standards for Medicare based on age. The remaining one-third of dual-eligible people meet the criteria due to a disability.

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Reduced Coverage / Medicare Cost Sharing Or Premium Payment

Qualified Medicare BeneficiariesCovered group: individuals covered by MedicareIncome limits: Income cannot exceed 100% of the federal poverty level. For more information, view the Guidelines for Medicare Cost-Sharing Programs brochure.Age: Medicare beneficiaries of any ageQualifications: Individuals must be eligible for Medicare Part A hospital insurance.

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Can You Have Medicare And Medicaid

The short answer is yes. If you receive coverage from both Medicaid and Medicare, youre a dually eligible beneficiary. If you are dual eligible, you may be enrolled in Medicare and then qualify for Medicaid, or enroll first in Medicaid but later qualify for Medicare. Medicaid assists seniors with limited income and people with disabilities also enrolled in Medicare.

How does dual eligibility work?

Dual-eligible beneficiaries can have:

Medicare Part AMedicare Part A, also called “hospital insurance,” covers the care you receive while admitted to the hospital, skilled nursing facility or other inpatient services. Medicare Part A is part of Original Medicare.
Medicare Part BMedicare Part B is the portion of Medicare that covers your medical expenses. Sometimes called “medical insurance,” Part B helps pay for the Medicare-approved services you receive.

Both Part A and Part B
Full Medicaid benefits
State Medicare Savings Programs

Medicare benefits always pay first, and Medicaid benefits assist with costs not fully covered by Medicare.

Medicaid will pay premiums and out-of-pocket expenses for dual-eligible Medicare beneficiaries. Medicare and Medicaid work together to cover costs, including long-term services. If you do not have full Medicaid benefits, Medicare Savings Programs may help cover some of those costs:

Are you eligible for cost-saving Medicare subsidies?

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How Old Do You Have To Be To Get Medicare Part D

To enroll in Medicare Part D, you must be enrolled in Medicare Part A. Thus, the age requirement for Medicare Part A will inherently become the age requirement for Medicare Part D.

This means, you will need to be at least age 65 or qualify for Medicare Part A based on disability status to enroll in Medicare Part D.

Explaining Medicaid Medicare & Dual Eligibility

A Special Enrollment for Dual Medicare/Medicaid Recipients

There are two key differences between the governmental health insurance programs Medicaid and Medicare:

Medicaid is run by ones state of residence, and Medicare is run by the federal government. Medicaid is for financially needy people who have monthly income and assets below a certain amount, while Medicare is for all Americans who are 65 or more years old and/or disabled.

Some benefits overlap, while others do not. Both programs pay for medical costs including doctor appointments and hospital care, but only Medicaid will cover all the costs of living in a nursing home for more than 100 days. Medicaid is also the program for receiving long-term care services at home or in assisted living, as Medicare does not pay for long-term care .

To be dual-eligible, one must meet the income requirements of their states Medicaid program, meaning having income and assets below a certain amount, and meet the age requirement for Medicare, meaning 65 and over. Put simply, dual eligibles will be low-income and above the age of 64.

Dual eligibles receive a combination of benefits from both programs.

Medicare Benefits

Medicare is broken into types: Medicare Part A provides hospital insurance . Medicare Part B is medical insurance . Medicare Part C is also called Medicare Advantage, and it provides benefits through a private insurer . Medicare Part D covers prescription drugs.

Medicaid Benefits

What Are Dual Special Needs Plans

Dual health plans are also known as Dual Special Needs Plans . Theyre offered by private insurance companies, so you can find a dual health plan that best meets your health insurance needs. Being on a dual health plan does not change your Medicaid eligibility or benefits.

See UnitedHealthcare plans in your area

Dual-eligible or Medicaid plan benefits can change depending on where you live. Search using your ZIP code to find the best plan to meet your health care needs.

Were here to help

Still have questions

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Looking for the federal governments Medicaid website? Look here at Medicaid.gov.

Who Is Eligible For Medicaid

You may qualify for free or low-cost care through Medicaid based on income and family size.

In all states, Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states the program covers all low-income adults below a certain income level.

First, find out if your state is expanding Medicaid and learn what that means for you.
If your state is expanding Medicaid, use this chart to see what you may qualify for based on your income and family size.

Even if you were told you didn’t qualify for Medicaid in the past, you may qualify under the new rules. You can see if you qualify for Medicaid 2 ways:

Visit your state’s Medicaid website. Use the drop-down menu at the top of this page to pick your state. You can apply right now and find out if you qualify. If you qualify, coverage can begin immediately.
Fill out an application in the Health Insurance Marketplace. When you finish the application, we’ll tell you which programs you and your family qualify for. If it looks like anyone is eligible for Medicaid and/or CHIP, we’ll let the state agency know so you can enroll.

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What Does Medicaid Cover For Adults

Mandatory benefits include services including inpatient and outpatient hospital services, physician services, laboratory and x-ray services, and home health services, among others. Optional benefits include services including prescription drugs, case management, physical therapy, and occupational therapy.

What Is The History Of Medicaid And How Is It Tied To Medicare

Medicaid and Medicare share a birthday, both born on July 30, 1965, when President Lyndon B. Johnson signed legislation creating a pair of programs designed to improve the healthcare options available to Americans.

While Medicare is a federal program focused on assisting Americans beginning at age 65, Medicaid is a federal/state partnership focused on those in need, regardless of age. Most states have adopted a federally backed expansion of Medicaid covered that debuted in 2014.

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Medicare And Medicaid Dual Eligibility

Because Medicare and Medicaid involve both state and federal governance, they are as complicated as you likely imagine. It is important to understand that Medicare and Medicaid are distinct programs and that some people are entitled to both.

Medicare is the federal governmentâs health insurance program that applies to people in the following categories:

Those who are over the age of 65
Younger people with certain kinds of disabilities
People who are afflicted with end-stage renal disease , which is a permanent kidney failure that requires either a transplant or dialysis

Medicaid provides healthcare coverage for many Americans in financial need. Those eligible can include any of the following who meet certain asset and income criteria:

Adults, including elderly adults
People with disabilities

Medicaid is funded by both the federal government and the state in which you live, making it exceptionally challenging to qualify without experienced legal guidance on your side.