Today in the United States, over 12 million people qualify as dual-eligible beneficiaries through Medicare and Medicaid, which means that they get their health care coverage from both programs.
You might qualify for dual-eligible coverage if you meet the following requirements:
- You qualify for your state’s Medicaid program (qualification is typically based on low income or disability).
- You are eligible for enrollment in Original Medicare Parts A (hospital insurance) and B (medical insurance).
So, how does dual eligibility work? Medicare is your primary payer and it covers inpatient hospitalization and outpatient medical services. After Medicare covers its share of your health care costs, Medicaid assists with certain Medicare costs like premiums, coinsurance, and copayments, as well as Extra Help with prescription drug costs. Also, depending on the program in your state of residence, Medicaid may cover some medical services that Medicare doesn’t include, like nursing facility care that exceeds Medicare’s 100-day limit, medical transport, vision, dental, and chiropractic care.
Can you enroll in a Medicare Advantage plan with Medicaid?
Even if you’re a dual-eligible beneficiary, you can still choose how you want to get your Medicare coverage, either through Original Medicare (Parts A and B) or a Medicare Advantage (Part C) plan.
If you decide to enroll in a Medicare Advantage plan, your state may offer special Part C plans specifically for dual-eligible beneficiaries. These Dual-eligible Special Needs Plans (D-SNPs) require you to live in the service area covered by the plan.
These plans include prescription (Part D) coverage, they typically cost less, and they are designed to make it easier and more affordable for dual-eligible beneficiaries to get their health care services.
Special Needs Plans
If this type of Medicare Advantage plan is available in your service area, you can enroll in it if any of the following requirements apply to you:
- You’re enrolled in Medicare and Medicaid.
- You require long-term care at home or in a facility
- You have a chronic or disabling condition like diabetes, cancer, dementia, or you’ve had a stroke.
Special Needs Plans (SNPs) are designed to provide benefits and services to enrollees who have specific health care needs due to an illness or disease. They cover the same benefits as Original Medicare Parts A and B, prescription drugs, as well as extra services that a person with special care needs might require.
You might become ineligible for an SNP if you no longer meet the eligibility criteria for the plan.
Depending on the state where you live, you might be automatically enrolled in a Medicare-Medicaid Plan if you are a dual-eligible beneficiary. However, you can choose a different Medicare plan if you don’t want to stay in that one.
You can enroll in a Medicare-Medicaid plan if you’re enrolled in Medicare, are receiving full Medicaid benefits, and meet any other requirements set by your state’s Medicaid program.
These types of plans help coordinate your Medicare and Medicaid benefits so it’s easier to get the services you need, but not all states offer them.
PACE (Program of All-Inclusive Care for the Elderly) plans
You can enroll in a PACE plan if you meet the following criteria:
- You have either Medicare, Medicaid, or both.
- You’re 55 or older.
- You reside in a PACE plan service area.
- You need care that is certified by your state as being nursing home-level care.
- You can live in the community safely if you receive help from a PACE plan.
PACE plans aren’t available in every state, but those that have them include Medicare prescription drug coverage, and don’t charge deductibles or copayments for drugs or health care services that are approved by the PACE plan.
PACE plans cover all the same benefits provided by Original Medicare Parts A and B and Medicaid. They also cover additional medically necessary health care services (or extended care beyond Medicare coverage) that can include the following:
- Adult primary care
- Dental care
- Emergency services
- Home care
- Inpatient hospital care
- Laboratory tests and X-rays
- Nursing home care
- Nutritional counseling
- Occupational and/or physical therapy
- Preventive care services
- Counseling by a social worker
- Transportation to and from PACE centers for activities, or to and from medical appointments.
For more information about enrollment in Medicare Advantage plans as a dual-eligible beneficiary, an independent, licensed sales agent may be able to help you compare plans and find the coverage that’s right for you.