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.
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Looking for the federal governments Medicaid website? Look here at Medicaid.gov.
What Is Pace For Medicare And Medicaid
Another Medicare and Medicaid program is PACE, or Programs of All-Inclusive Care for the Elderly.
PACE helps older Medicare beneficiaries to seek health care within their community, in their home and at PACE facilities.
Some of the things that can be covered by PACE include:
- Adult day primary care
- Caregiver training
- Transportation to a PACE facility when medically necessary
PACE is not strictly restricted to Medicare dual eligible beneficiaries. You may be eligible for PACE with only Medicare or only Medicaid .
However, you must meet all of the following conditions:
- Be at least 55 years old
- Live in the service area of a PACE organization
- Require a nursing home-level of care
- Be able to live safely in the community with help from PACE
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Becoming A Dual Eligible Can Help Older Americans Pay Out
by Dena Bunis, AARP, November 13, 2018
En español | Every year many Medicare beneficiaries are surprised to learn that they can face thousands of dollars in costs above what the federal government pays for their health care.
There are premiums, deductibles, copays and coinsurance costs that vary depending on whether you select original Medicare or a Medicare Advantage plan, where you live, how healthy you are and how much medicine you take.
But there is some financial relief available for older Americans who have low or very low incomes and few assets. Depending on your finances, you could qualify to become what is called a dual eligible, someone who can enroll in both Medicare and Medicaid. Even if your income is not low enough for you to qualify for full Medicaid benefits, you may be eligible for one of the four Medicare Savings Programs that can help you pay for all or some of those costly out-of-pocket Medicare expenses. And you can enroll in Medicaid and the savings programs at any time not just during the Medicare open enrollment period.
Medicaid is funded by both the federal and state governments. While there are some national eligibility and benefit requirements, each state has its own Medicaid eligibility standards and decides which optional services it will cover and how much it is willing to pay for health care that Medicare doesnt cover.
Heres what you need to know about the dual eligible programs:
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Medicare Advantage And Medicaid Whats The Difference
The Medicare Advantage program is considered a âpartâ of Medicare â Medicare Part C. If you qualify for both Medicare and Medicaid, you can generally sign up for a Medicare Advantage plan. Or, you might want to look into the Medicare Savings Programs described above.
Many people prefer Medicare Advantage plans as a way to get their Medicare coverage. Medicare Advantage is a program that lets you get your Medicare Part A and Part B benefits through a private, Medicare-approved insurance company. Many plans have extra benefits, too, like prescription drug coverage and routine dental care.
How Do You Qualify For Medicaid
You qualify for Medicaid based on your finances. Medicaid needs to see difficulties with one of two things:
What are the income requirements?
Medicaid is primarily a state-run program. Each state runs its own Medicaid program the way it sees fit. They also set local financial standards to receive Medicaid benefits.
Thats why you may qualify for Medicaid benefits when you apply, but your friend with similar income and assets who lives in a different state doesnt. It all depends on where you live.
Medicaid has two funding sources: the state and the federal government. Therefore, the money to operate Medicaid is split between the federal governments contribution and the taxes a state collects.
Keep in mind that annual income limits for Medicaid are indexed to the federal poverty level. In 2021, the limit in the continental U.S. was $12,880 for an individual and $17,420 for a couple.
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What Is Fbde For Medicare And Medicaid
Full-Benefit Dual-Eligible individuals are eligible for Medicare and full Medicaid benefits through their state. FBDE beneficiaries qualify for coverage of the following through Medicare Savings Programs: Medicare Part A and Part B premiums, deductibles, coinsurance, and copays. FBDE beneficiaries often pay $0 out-of-pocket for any medically necessary healthcare services.
If I Have Medicaid Do I Need Medicare Part D
Those that have Medicare and Medicaid will automatically be enrolled in a Part D plan if they dont select one for themselves. Its in the enrollees best interest to select a policy to enroll in, instead of being dropped into a plan. But, either way, Medicaid will help cover the costs associated with premiums, copayments, or coinsurances.
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If I Am A Dual Eligible Beneficiary What Are My Options For Healthcare Insurance Plans
Those who qualify for both Medicare and Medicaid have a lot of options for how they may wish to receive their health insurance plan and how their healthcare treatments and services are delivered.
The number of options always varies at the state level, but generally, dual eligible individuals can choose to receive health insurance coverage through the following:
I Have Been Receiving Health Care Through Medicaid Will I Lose This Coverage When I Become Eligible For Medicare
En español | You will not lose Medicaid eligibility just because you become entitled to Medicare. As long as your income falls under the limits for Medicaid eligibility in your state, you will receive both types of coverage. More than 8 million people have both Medicare and Medicaid.In this situation, Medicare becomes your primary insurance and settles your medical bills first and Medicaid become secondary, paying for services that Medicare doesnt cover and also paying most of your out-of-pocket expenses in Medicare .When you become eligible for Medicare, you must begin receiving your prescription drug coverage from Medicares Part D drug program, not from Medicaid. You will automatically qualify for the federal Extra Help program, which enables you to receive Part D drug coverage without paying premiums or deductibles and paying only low copays for your drugs. But to get this coverage, you still have to choose a Part D drug plan and enroll in it. To ensure that you pick a plan that gives you maximum coverage at the lowest cost, you may want to contact your state health insurance assistance program , which provides personal help from trained counselors on all Medicare and Medicaid issues free of charge. To find the main toll-free number of your SHIP , go to www.shiptacenter.org and select your state.
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Distinguishing Between Medicare And Medicaid
Applicants qualified for both Medicare and Medicaid programs are referred to as Medicare-Medicaid enrollees having dual eligibility. Since the terms Medicare and Medicaid can be easily confused, it is essential to distinguish between them. While Medicare coverage is a federal health insurance program for seniors and people with disabilities, Medicaid is a state and public medical assistance program for people of all ages who need financial support. Both programs provide several benefits, such as doctor visits and hospitalization, but only Medicaid offers long-term nursing care. Particularly relevant to the subject of this article, Medicaid also covers long-term care and supports in-home and community-based settings, such as ones own home, an adult foster care residence, or an assisted living facility. However, beginning in 2019, Medicare Advantage plans began providing some long-term home and area-based benefits.
The CMS is in charge of both the Medicare and Medicaid programs. CMS collaborates with state agencies to administer the Medicaid program in each state, whereas the Social Security Administration applies for Medicare.
Do I Qualify For Full Medicaid
- The eligibility requirements vary from state to state, but generally states consider your annual income and financial assets when determining whether you are eligible for full Medicaid.
- If you live in one of the 37 states that will have expanded Medicaid as of next January and you earn no more than 138 percent of the federal poverty level , you may qualify. In states that havent expanded the program, the income levels for Medicaid eligibility vary greatly. For all eligibility questions, you should check with your state Medicaid office.
- If you are a Medicare beneficiary, your enrollment in Medicaid may be subject to a financial asset test. The value of assets youre allowed to have and still be eligible varies from state to state. The federal guidelines allow you $2,000, but some states have higher thresholds while others dont have an asset test at all.
- Excluded from the $2,000 asset test are such things as your home, one car, some burial expenses, some life insurance and household and personal items. States generally look back at an applicants assets for five years to make sure they havent divested themselves of those resources just to qualify for Medicaid.
- The asset income limits for Medicare Savings Programs are higher and change every January. For 2018, the limits for those programs are $7,560 for a single person and $11,340 for a married person living with a spouse and no dependents. As with full Medicaid, some states have higher resource thresholds.
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Qualified Medicare Beneficiary Or Qmb
The QMB program assists beneficiaries in paying Medicare Part A and Part B monthly payments, coinsurance, and deductibles. As a general rule, the income limit is set at 100% of the Federal Poverty Level plus a $20 allowance. This means that a single candidate can earn up to $1,093 per month, and a married couple can earn up to $1,472 per month. The asset thresholds are higher than those for full Medicaid coverage. A single applicants limit is $7,970, and a married couples limit is near $11,960.
Unitedhealthcare Senior Care Options Plan
UnitedHealthcare SCO is a Coordinated Care plan with a Medicare contract and a contract with the Commonwealth of Massachusetts Medicaid program. Enrollment in the plan depends on the plans contract renewal with Medicare. This plan is a voluntary program that is available to anyone 65 and older who qualifies for MassHealth Standard and Original Medicare. If you have MassHealth Standard, but you do not qualify for Original Medicare, you may still be eligible to enroll in our MassHealth Senior Care Option plan and receive all of your MassHealth benefits through our SCO program.
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People Who Have Both Medicare & Medicaid
People who have both Medicare and full Medicaid coverage are dually eligible. Medicare pays first when youre a dual eligible and you get Medicare-covered services. Medicaid pays last, after Medicare and any other health insurance you have.
You can still pick how you want to get your Medicare coverage: Original Medicare or Medicare Advantage . Check your Medicare coverage options.
If you choose to join a Medicare Advantage Plan, there are special plans for dual eligibles that make it easier for you to get the services you need, include Medicare coverage , and may also cost less, like:
- Special Needs Plans
- Medicare-Medicaid Plans
- Program of All-Inclusive Care for the Elderly plans can help certain people get care outside of a nursing home
Levels Of Medicaid Coverage
Full dual eligible coverage
Qualifications for Medicaid vary by state, but, generally, people who qualify for full dual eligible coverage are recipients of Supplemental Security Income . The SSI program provides cash assistance to people who are aged, blind, or disabled to help them meet basic food and housing needs. The maximum income provided by the federal government for SSI in 2020 is $783 per month for an individual and $1,175 per month for a couple.2
To qualify for SSI, you must be under a specified income limit. Additionally, your assets must be limited to $2,000 for an individual and $3,000 for a couple.3 Qualifying assets typically include things like checking and savings accounts, stocks, real estate , and vehicles if you own more than one.
Partial dual eligible coverage
Individuals who are partial dual eligible typically fall into one of the following four Medicare Savings Program categories.
Monthly income limit: $1,456 for an individual, $1,960 for a coupleResource limit: $7,860 for an individual, $11,800 for a couple
Helps pay for Part B premiums
Qualified Disabled Working Individual Program
Monthly income limit: $4,339 for an individual, $5,833 for a coupleResource limit: $4,000 for an individual, $6,000 for a couple
Pays the Part A premium for certain people who have disabilities and are working
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Do You Get Guaranteed Issue Rights For Loss Of Medicaid Coverage
If you are dual-eligible for Medicare and Medicaid and find yourself in a situation where your income increases and exceeds your state Medicaid requirements, you will receive guaranteed issue rights in certain states. However, not all states grant beneficiaries these rights when they lose Medicaid eligibility.
If your state grants guaranteed issue rights in this scenario, you would be eligible to enroll in the Medicare Advantage or Medicare Supplement plan of your choice.
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Using Your Healthy Connections Plan
Q. What medical services does Medicaid cover? A. Within certain limits, Medicaid will pay for services that are medically necessary. Examples of services that may be covered include doctor visits, medications, hospital visits, and many other medical services.
If you have any questions about what is covered, to view a chart that shows each health plan and what they cover. You can also contact Healthy Connections toll-free at 1-888-549-0820.
Q. How long will my Medicaid benefits remain active? A. Eligibility for most Healthy Connections programs lasts for 1 year. After 1 year, South Carolina Health and Human Services will review your case annually.
Q. I was enrolled in S.C. Healthy Connections Choices and now am told I must choose between health plans. What should I do? A. The Healthy Connections Choices website offers comprehensive information on its health plans. Members may utilize a Quick Start Guide, search for doctors, compare plans, and more. Please visit S.C. Healthy Connections Choices for more information.
Q. Do I need to tell South Carolina Healthy Connections when I move or change jobs? A. Yes. If you have any changes to your income, resources, living arrangements, address or anything else that might affect your eligibility you must report these changes to Healthy Connections right away at 1-888-549-0820.
Q. What if my Medicaid card is lost or stolen? A. Report a lost or stolen card to Healthy Connections immediately at 1-888-549-0820.
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Does Medicaid Pay What Medicare Doesn T
Both Medicare Part A and Part B copays and coinsurance. The Medicare Part D premium, deductibles and copays for prescription drugs. 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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What Steps Do I Need To Take To Move From Expanded Medicaid To Medicare
If youre enrolled in expanded Medicaid and youll soon be 65, youll want to familiarize yourself with the health coverage and assistance programs that might be available to you.
Understand that although your assets have not been taken into consideration to determine your eligibility for expanded Medicaid, that will likely change when you turn 65. Every state has an asset limit for full Medicaid eligibility if youre 65 or older, and most states also have asset limits for their MSPs.
But if you do qualify for an MSP particularly the Qualified Medicare Beneficiary program along with Extra Help for prescription drugs you may find that you still qualify for premium-free coverage and very limited out-of-pocket costs.
Youll want to reach out to your states Medicaid office prior to turning 65, to be sure you understand the specifics of 65+ Medicaid and MSP eligibility.
You can also reach out to the Medicare SHIP in your state, to see what resources and assistance are available to you.
You might also want to find a Medicare broker who can help you understand the available Medigap, Part D, and Medicare Advantage plans. Your limited income might make you a good candidate for a low-cost or zero-premium Medicare Advantage plan, leaving you with just the cost of Medicare Part B.
Heres more about choosing between Medigap and Medicare Advantage theres no single solution that works for everyone, so take your time and compare the options available to you.
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What Is The General Difference Between Medicaid And Medicare
Medicaid is a government assistance program that typically covers medical costs for low-income individuals, including pregnant individuals and children. Individuals must qualify for Medicaid based on their states requirements. Medicare is a government health insurance program for which most people at least 65 years old qualify.