In the United States, there are over 12 million Medicare beneficiaries who also have coverage through Medicaid services in their states. Known as dual eligible beneficiaries, this group consists mainly of seniors who have limited income and a greater need for health care coverage. With dual eligibility, beneficiaries get health care coverage through Medicare, while Medicaid helps them pay Medicare premiums and other out-of-pocket expenses.
To be eligible for dual coverage, you must qualify for your state’s Medicaid program and Original Medicare Parts A and B. If you choose to enroll in a Medicare Advantage Dual-Eligible Special Needs Plan (D-SNP), you have to live within the service area covered by the plan.
To qualify for your state’s Medicaid program, you must meet the income requirements set by your state. Depending on where you live, you may also have restrictions based on the size of your household, disability, family status, and other conditions.
If you live on a limited income, you may qualify for dual eligibility. Understanding how Medicare insurance works with Medicaid can help you determine how much your health care will cost.
How do Medicare and Medicaid work together?
Even if you have full dual eligible status, Medicare still pays for your health care services as your primary payer. After Medicare pays its share of your expenses, Medicaid helps pay for some out-of-pocket expenses and non-covered health care services that Medicare doesn’t include. However, your exact Medicaid coverage allowance depends on which state you live in.
When you are eligible for Medicare, you can get your coverage through Original Medicare Parts A (hospital insurance) and B (medical insurance), or you can enroll in a Medicare Advantage (Part C) plan.
If a D-SNP is offered in your area, you may choose to enroll in Medicare Advantage. These specialized plans help beneficiaries get the health care services they need, and they typically include prescription drug benefits (Medicare Part D).
Are you fully dual-eligible for Medicare and Medicaid?
If you qualify for Medicare and full Medicaid based on low income and resources, you will have the opportunity to decide if you’d like to keep Original Medicare or Medicare Advantage. A D-SNP will include prescription drug (Medicare Part D) benefits and can help you coordinate your dual coverage, so you get covered services more easily.
D-SNPs aren’t available in every state, so you should contact the State Medical Assistance (Medicaid) office in your service area to find out whether your state offers them.
To be eligible for this type of plan, all the following conditions must apply:
- You are enrolled in Medicare
- You are receiving full Medicaid benefits
- You meet your state’s eligibility criteria
Special Needs Plans are a type of Medicare Advantage plan that’s customized for a specific need or circumstance. Dual-eligible SNPs will provide benefits, provider networks, and drug formularies to meet the health care needs of their enrollees. They all include Medicare prescription drug coverage.
You may qualify for a number of reasons, including but not limited to the following criteria:
- You are enrolled in Medicare and Medicaid.
- You need long-term care either at home or in a facility.
- You have a condition that’s chronic or disabling such as diabetes, cancer, dementia, etc.
What is PACE?
Programs of All-Inclusive Care for the Elderly,or PACE, is a Medicare and Medicaid program that works with your community to help provide you with the coordinated care you require without moving into assisted living. PACE isn’t available in every state, so you should contact a local CMS office for more information about availability.
You may qualify for a PACE plan if you meet the following requirements:
- You are enrolled in either Medicare or Medicaid or both.
- You are 55 years old, or older.
- You reside in a PACE plan service area.
- Your state certifies that you require nursing home-level care.
- You can live in your community safely when assisted by the PACE program.
To get more information about what plans are available in your area, you can call a local CMS office or your state’s Medical Assistance office.