Dual Complete Medicare And Medicaid

Medicare Dual Eligible Special Needs Plans

Another type of coverage that may be available to dual eligible beneficiaries is a Medicare Dual Eligible Special Needs Plan .

A Medicare special needs plan is a certain type of Medicare Advantage plan that is designed for people with specific health conditions or circumstances.

A D-SNP is built for the specific needs of dual eligibles. All Medicare SNPs provide prescription drug coverage.

What Medicaid Covers For Medicare Enrollees

Medicare has four basic forms of coverage:

• Part A: Pays for hospitalization costs
• Part B: Pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services
• Part C: Medicare Advantage Plan offered by private companies approved by Medicare
• Part D: Assists with the cost of prescription drugs

Medicare enrollees who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medicaid . Medicaid also covers additional services beyond those provided under Medicare, including nursing facility care beyond the 100-day limit or skilled nursing facility care that Medicare covers, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the states payment limit.

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Extra Help With Costs: Lis Premium Summary Table

UnitedHealthcare Dual Complete®

Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get extra help.

*This does not include any Medicare Part B premium you may have to pay.

If you arent getting extra help, you can see if you qualify by calling:

• 1-800-Medicare of TTY users call 1-877-486-2048 ,
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

Your health care needs are unique. These documents can help you make sure you get the right coverage.

Documents include Annual Notice of Changes, Evidence of Coverage, Formularies, Medicare Plan Star Ratings, Provider Directories, Summary of Benefits, Other downloadable resources.

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Understanding The Difference Between Medicare And Medicaid

It is possible to use both Medicare and Medicaid to help with the cost of medical procedures and exams, but you should know how the two programs are different.

Medicare offers health insurance benefits to people who are at least 65-years-old or for people who have disabilities or kidney failure. This kind of insurance is provided by the U.S. federal government and consists of multiple parts that cover different medical needs, such as hospital insurance, medical insurance and prescription medications.

Medicare also offers another option Medicare Advantage Plan that allows people to receive their Medicare benefits through a private insurance company. This avenue allows beneficiaries to customize their health insurance needs.

Medicaid is a state program that helps low-income individuals and families with the costs of healthcare. This is different from Medicare because you do not have to have a disability or be over the age of 65 to receive health insurance benefits.

Medicaids goal is to help people who truly cannot afford the cost of health services because of their income level regardless of age. People who qualify for Medicaid may get assistance paying for premiums, deductibles, coinsurance, copayments, and prescription drugs. And in some cases, Medicaid covers things that Medicare will not, such as the cost of nursing home stays or personal care attendants.

Detailed Reporting Expectations In T

The State Medicare Modernization Act Files of Dual Eligibles are considered to be reliable, current sources of information on the dual-eligible population. States submit these files monthly to CMS for purposes related to the administration of Medicare Part D benefits. Because the T-MSIS and MMA counts by dual code both count the same populations on a monthly basis, they are expected to be generally consistent. States can therefore consider these MMA files as a useful resource for validating dual code classifications in T-MSIS .

It is also important to remember the intent behind dual codes 08 and 09, which are broader dual categories, to ensure that they are being assigned correctly:

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What Are The Benefits Of Being Dual Eligible In 2022

If you are dual eligible, you can benefit from both Medicare and Medicaid. You may also qualify for a Medicare Savings Program .

A Medicare Savings Program is a federally funded program administered by individual states that helps people who have limited financial resources pay for costs like Medicare premiums, deductibles, copayments and coinsurance.

There are four types of Medicare Savings Programs:

What To Consider When Enrolling In A D

You cannot enroll in both a D-SNP and a Health Home program. Enrollment into a D-SNP will disenroll you from your Health Home program. For more information on the Health Home program, see the Health Home page.

You have the option to choose the plan for your D-SNP and BHSO coverage if you live in a county that offers aligned enrollment.

Aligned enrollment helps dual-eligible clients manage their physical and behavioral health services under one plan. This makes it easier to find a provider and coordinate your Medicare and Apple Health services.

View the aligned enrollment map in our service area guide to see if alignment is available in your county.

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Dual Eligible Special Needs Plans Can Help Coordinate Your Medicare And Medicaid

A Dual Eligible Special Needs Plan, also called a D-SNP, is a kind of Medicare Advantage plan for people who have both Medicare and Medicaid.

D-SNPs cover hospital, medical, and prescription costs all in one plan, with no or low costs. These plans have provider networks, which means that you must see doctors who are in-network for the plan to help pay your medical bills.

D-SNPs work best when you are enrolled in the same companys health maintenance organization for your Medicaid. That way, the same company is providing both your Medicare and Medicaid coverage.

Medicare and Medicaid usually don’t coordinate. Separate companies provide managed care for each plan.

If you have a Medicare D-SNP and Medicaid HMO or managed care organization through the same company, Medicare and Medicaid benefits are coordinated.

Whats The Difference Between Medicaid And Medicare

Medicaid is an assistance program. For anyone that qualifies, Medicaid enrollment is open the entire year. Most Medicaid enrollees lack access to affordable quality health insurance. Medicaid patients usually do not pay the costs of covered medical services. When its time to enroll in Medicaid, it is essential to know your state-level program follows federal guidelines for standard coverage but may have expanded coverage.

Medicare is a public health insurance program. Most people that use Medicare are 65 years of age or older. Patients pay part of their medical costs through deductibles and premiums. Medicare is a federal program and is administered the same nearly everywhere in the United States. Medicare enrollment is available at specific times during the year, including Initial Enrollment, Annual Enrollment Period , Medicare Advantage Open Enrollment , and Special Election Periods .

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Special Enrollment Periods If You Get Extra Help

I’m eligible for both Medicare and Medicaid.

What can I do?

Join, switch, or drop your Medicare Advantage Plan or Medicare prescription drug coverage.

When?

One time during each of these periods:

If you make a change, it will take effect on the first day of the following month. Youll have to wait for the next period to make another change. You cant use this Special Enrollment Period from OctoberDecember. However, all people with Medicare can make changes to their coverage from October 15December 7, and the changes will take effect on January 1.

I qualify for Extra Help paying for Medicare drug coverage.

What can I do?

Join, switch, or drop Medicare drug coverage.

When?

Most people with Medicare can only make changes to their drug coverage at certain times of the year. If you have Medicaid or receive Extra Help, you may be able to make changes to your coverage one time during each of these periods:

What Is Medicare Dual Eligible And How Do I Qualify

Most Americans understand that when they turn 65, Medicare will become their main health insurance plan. However, many Americans are less familiar with another health care program, Medicaid, and what it means if they are eligible for both Medicare and Medicaid. If you are dual eligible, Medicaid may pay for your Medicare out-of-pocket costs and certain medical services that arent covered by Medicare.

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Health Services Not Covered By Medicare

Medicare is not an all-inclusive program. With rare exceptions, Original Medicare does not cover dental, hearing, and vision screening. That leaves beneficiaries to scramble for dentures, hearing aids, or corrective lenses . People who decide to enroll in Medicare Advantage may choose a plan that offers coverage for some of these services.

If your state Medicaid program offers these services, you may benefit from the added coverage. Not all states will offer coverage and if they do, it may not be available to everyone who qualifies for Medicaid.

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Can You Have Medicare And Medicaid

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 low-income seniors, and people with disabilities also enrolled in Medicare.

How does dual eligibility work?

Dual-eligible beneficiaries can have:

• 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:

• Qualified Medicare Beneficiary Program
• Specified Low-Income Medicare Beneficiary program
• Qualifying Individual Program
• Qualified Disabled and Working Individuals Program

Medicaid may also cover prescription drugs, eyeglasses, and hearing aids. Medicaid covers any qualified medical costs not covered by Medicare up to your states payment limit. A GoHealth licensed insurance agent can help you navigate enrollment, identify available subsidies, and find the right coverage. You may also find information on your states Medicaid website.

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Having Dual Eligibility For Medicaid & Medicare: Who Is Eligible And Benefits

SummaryMedicaid is a health insurance program run by each individual state for people who are low-income, and Medicare is a national health insurance program for all Americans over 65. People who are eligible for both Medicaid and Medicare are considered dual eligibles. While some benefits are available through both programs, there are also differences in coverage that make dual eligibility a good way for many seniors to pay for their care needs. Only Medicaid, for example, pays for long-term nursing home care.

What Is Covered By Medicare Vs Medicaid

Medicare

Depends on the coverage you choose and may include:

• Care and services received as an inpatient in a hospital or skilled nursing facility
• Doctor visits, care and services received as an outpatient and some preventive care
• Prescription drugs
• Medicare Advantage plans: combine Part A and Part B coverage, and often include drug coverage , as wellall in one plan.

Medicaid

Each state creates its own Medicaid program, but has to follow federal guidelines, like the required and optional benefits they include. Some of the benefits Medicaid programs have to include are:

• Care and services received in a hospital or skilled nursing facility
• Care and services received in a federally-qualified health center, rural health clinic or freestanding birth center
• Doctor, nurse midwife, and certified pediatric and family nurse practitioner services

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Where Do I Get Started

We know that it can be stressful to navigate the insurance coverage process, but we strive to make it as smooth as possible.

We accept a variety of plans from insurance companies at all of our locations. To verify if your insurance plan is accepted for services across our health system, please review our list of accepted insurance companies below.

If your insurance company is accepted by Cleveland Clinic: Please contact your insurance company to confirm what care is covered by your plan as well as information on copayments, deductibles and coinsurance amounts. See what your out-of-pocket expenses will be using our cost estimator.

If your insurance company is not accepted by Cleveland Clinic: This means your insurance plan is considered out-of-network which can lead to greater out-of-pocket expenses for your care. Please contact your insurance company for more information about what your financial responsibility may be if you choose to receive care at Cleveland Clinic. Find more information about Cleveland Clinics out-of-network insurance process.

What Type Of Coverage Do You Get If You Are Dual Eligible For Medicare And Medicaid

There are two levels of coverage for beneficiaries who are dual eligible:

• Full dual eligibleFull dual eligible refers to those who receive full Medicaid benefits and are also enrolled in Medicare. People who are full dual eligible typically receive Supplemental Security Income benefits, which provide cash assistance for basic food and housing needs. Qualifying as full dual eligible is based on your assets, which include checking and savings accounts, stocks, real estate and vehicles .
• Partial dual eligiblePartial dual eligibility includes those who receive assistance from Medicaid in order to help pay for Medicare costs such as premiums, coinsurance or deductibles. Partial dual eligibles fall into one of four categories of eligibility for Medicare Savings Programs.

A Medicare Savings Program is a federally funded program administered within each state that helps lower income people pay for Medicare premiums, deductibles, copayments and coinsurance.

The four Medicare Savings Programs are outlined below.

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What Is Medicare Extra Help

Extra Help is a federal program that helps pay for out-of-pocket costs related to Medicare prescription drug coverage. Extra Help is also known as the Medicare Part D Low-Income Subsidy

The assistance that Medicare Extra Help may provide includes:

• Help paying Part D premiums
• Lowered out-of-pocket costs of prescription drugs
• An annual Special Enrollment Period to enroll in a Part D plan or switch to a new one
• Elimination of Part D late enrollment penalties

You automatically qualify for Extra Help if you are enrolled in Medicaid, Supplemental Security Income or a Medicare Savings Program.

You may still qualify for Extra Help if you are not enrolled in any of those programs but still have income and assets below a certain limit.

Eligibility & How To Apply For Medicaid & Medicare

MedicareThere is no difference in eligibility criteria from state-to-state for Medicare its the same throughout the US. The broad requirements for Medicare eligibility are that the applicant must be the following: A U.S. citizen for at least 5 years before applying At least 65 years old or disabled.

To apply for Medicare, contact the nearest Social Security Office.

Medicaid Medicaid eligibility is complicated and will vary depending on several factors including ones financial situation and state of residence.

To enroll in Medicaid, ones monthly income and countable assets must be below a certain amount that, again, will vary depending on the state. Our Medicaid Long Term Care Eligibility Requirements Finder is a great place to start learning the eligibility requirements specific to your state, type of Medicaid and marital status.

For much more on eligibility for Medicaid, .

To apply for Medicaid, contact your nearest Medicaid office.

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What Are My Costs With Dual

Dual-eligibility can limit individual costs for beneficiaries. For those with Medicare, state Medicaid programs will pay for many cost-sharing and out-of-pocket expenses for medical services. For any service you receive, Medicare pays first and covers all eligible costs. Any qualified costs not covered by Medicare will be covered by Medicaid.

What Are Dual Health Plans

Dual health plans are designed just for people who have both Medicaid and Medicare. Theyre a special type of Medicare Part C plan. Dual health plans combine hospital, medical and prescription drug coverage. Youll keep all your Medicaid benefits. Plus, you could get more benefits than with Original Medicare. And you could get it all with as low as a $0 plan premium.

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