The Parts Of Medicare
Social Security enrolls you in Original Medicare .
- Medicare Part A helps pay for inpatient care in a hospital or limited time at a skilled nursing facility . Part A also pays for some home health care and hospice care.
- Medicare Part B helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment, and some preventive services.
Other parts of Medicare are run by private insurance companies that follow rules set by Medicare.
- Supplemental policies help pay Medicare out-of-pocket copayments, coinsurance, and deductible expenses.
- Medicare Advantage Plan includes all benefits and services covered under Part A and Part B prescription drugs and additional benefits such as vision, hearing, and dental bundled together in one plan.
- Medicare Part D helps cover the cost of prescription drugs.
Most people age 65 or older are eligible for free Medical hospital insurance if they have worked and paid Medicare taxes long enough. You can enroll in Medicare medical insurance by paying a monthly premium. Some beneficiaries with higher incomes will pay a higher monthly Part B premium. To learn more, read .
What The Part B Late Enrollment Penalty
If you do not have creditable coverage after you first become eligible for Medicare Part B, you incur a penalty that you will pay when you eventually do enroll in Part B.
The late enrollment penalty fee amount is a 10 percent increase in your Part B premium for each 12-month period you could have enrolled in Part B but did not.
- For example, if you did not enroll in Part B when first eligible and delayed your enrollment for 14 months , your standard Part B premium amount including your late enrollment penalty would be $187.11 per month.
- This total includes the standard Part B premium of $170.10 per month, plus your late enrollment penalty of $17.01 per month .
If you qualify for a Medicare Special Enrollment Period, you may not be required to pay the late enrollment penalty.
What Is Substantial Gainful Activity
Social Security uses the term “substantial gainful activity” to describe a level of work activity and earnings. If you receive SSDI, Social Security uses SGA to decide if your eligibility for benefits continues after you return to work and complete your TWP. Social Security generally compares your monthly earnings to set amounts, known as earnings thresholds, to evaluate if your work activity is SGA.
After you start working, your Medicaid coverage can continue, even if your earnings become too high to receive SSI. Under the Continued Medicaid Eligibility Work Incentive ), you may qualify for continued Medicaid coverage when your SSI payments stop if you:
- Have been eligible for an SSI benefit for at least one month.
- Continue to be disabled .
- Meet all other non-disability SSI requirements, including the resources test.
- Need Medicaid in order to work.
- Have gross earned income that are below your state’s threshold of eligibility.
If your gross earnings are higher than your state’s threshold amount, Social Security can calculate your individual threshold amount if you have:
- A plan to achieve self-support .
- Publicly-funded attendant or personal care.
- Medical expenses that exceed the state per-capita amount.
In some states, through the Medicaid Buy-In Program you may be able to apply to buy Medicaid from the state Medicaid agency if you are disabled and no longer entitled to free Medicaid because you work. You may qualify if you:
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The Solution: Medicaid Could Make Up The Medicare Difference For You
Some people think that Medicaid is welfare, but that is not true. Medicaid covers medical expenses, long-term care services, case management, and much more. Medicaid is a different program than Medicare.
Medicaid is for people whose incomes are close to the federal poverty line. Today, Medicaid provides extra help paying doctor bills, hospital bills, and prescriptions for millions of Americans aged 65 and over. If you fall into this category, then youll want to take a close look at your Medicaid eligibility.
Not Limited to Seniors
Others besides seniors can receive Medicaid benefits 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. People with a disability or certain medical conditions may qualify for Medicaid at any age.
What Are Dual Health Plans
Dual health plans are specifically designed for those who are dual eligible, and have both Medicare and Medicaid. They are a special type of Part C plan and they combine hospital, medical and prescription drug coverage. In most cases, there is a $0 premium.
These plans are offered by private insurance companies, so you can find one that best meets your coverage and health care needs.
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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:
Moving From Expanded Medicaid To Medicare Advantage
Depending on your circumstances, you might choose to enroll in a Medicare Advantage plan that provides prescription, dental, and vision coverage and caps enrollees annual out-of-pocket costs for Parts A and B, which traditional Medicare does not do. Many of these plans are available with no additional premiums, which means youd pay just the $148.50/month for your Part B coverage .
And some Medicare Advantage plans even have a give back benefit that pays some of that Part B premium for you.
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Who Doesnt Qualify For Medicaid
One in five Americans has Medicaid coverage. Those who do not qualify are:
- People with incomes that are higher than the limit set by the state in which they live. These limits vary among the states but are more stringent in those states that did not choose to expand Medicaid coverage under the Affordable Care Act .
- People who are not U.S. citizens or do not meet the requirements for a lawful, permanent resident.
- People who previously qualified but have a status change for instance, they are no longer pregnant, their income has increased through employment or gift/inheritance, or they have moved to a state with different eligibility requirements.
- People who do not report status changes in a timely manner or who fail to renew during the redetermination period may lose their benefits. Under federal law, you have 90 days to provide your state Medicaid agency with all required information after you lose coverage.
Where Can I Find Out More
- Medicaid.gov has links to information explaining the program and to every states Medicaid office.
- Each state has a State Health Insurance Assistance Program that provides counseling and help for Medicare beneficiaries. SHIP counselors can answer some of your Medicaid questions and refer you to local Medicaid officials to help with others.
- The National Council on Aging has a benefits checkup website that has information on Medicare, Medicaid and other programs that help older Americans.
More on Medicare
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Medicaid Doctors And Costs
A great way to find providers in your area who accept Medicaid is by using an online search tool like DocSpot. From DocSpot, youll enter your city, your type of coverage , and the type of doctor you are looking for. DocSpot will populate results for you where you can read reviews and pick Medicaid doctors in your area that you can schedule an appointment with.
If you have both Medicare and Medicaid, you can expand your doctor network to also include those who accept Medicare. If you have Medicare Advantage , youll want to use your plans website to search for a provider that accepts your coverage.
Your Medicaid, Medicare, and Medicare Advantage costs will all depend on your financial status and the type of plan you select.
Qualified Disabled And Working Individual
You may be eligible to purchase Medicare Part A benefits, but unable to afford it because of your low income. In this case, Medicaid will pay your Medicare Part A premium. This is more common with people under the age of 65.
In 2021, the maximum monthly income to qualify is $4,379 for an individual and $5,892 for a couple. The 2021 maximum asset level, however, is set at just $4,000 for an individual and $6,000 for a couple.
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Qualifying Medicaid Beneficiary Only
This is for people who are not eligible to receive full Medicaid benefits. Medicaid will pay the recipients Medicare Part A premiums . It will also pay their Medicare Part B premium for them. Besides, there may be extra help with Medicare insurance deductibles and copayments.
If youre a QMB recipient, you chose the Medicare insurance that you like. Then, Medicaid helps with your deductibles and copayments.
You will want to have good Medicare insurance, like a Medicare Advantage plan, in place if you receive Medicaid benefits. Remember, QMB is a dual-eligible program, not a Medicaid-only program.
Maximum monthly income for those aged 65 and over to qualify for QMB in 2021 is $1,094 for an individual and $1,472 for a couple. For 2021, the maximum asset level is $7,970 for an individual and $11,960 for a couple.
In certain situations like nursing home benefits, people with greater assets may be asked to spend down their assets first before Medicaid kicks in with help.
Transitioning From Expanded Medicaid To Medigap
The more expensive way to cover the gaps in traditional Medicare is to buy a Medigap policy, which generally costs anywhere from a minimum of $25/month to more than $200/month to cover out-of-pocket costs for Parts A and B. Thats on top of premiums for Medicare Parts B and D .
The payoff is maintaining unlimited access to all healthcare providers who accept Medicare which almost all providers do. Heres more about choosing between Medigap and Medicare Advantage.
Can You Enroll In A Medicare Advantage Plan When Youre On Medicaid
You might be able to sign up for a Medicare Advantage plan when youâre on Medicaid. For example, there are some Medicare Advantage plans called Special Needs Plans .
There are several types of SNPs. One of them is specifically tailored for dual-eligibles. Itâs sometimes called a D-SNP. However, be aware that D-SNPs might not be available in your area.
If you want to sign up for a Medicare Advantage plan when youâre on Medicaid, you can:
- Contact your local State Health Insurance Assistance Program .
Please note that your Medicare Part B premium still applies when you have a Medicare Advantage plan. If youâre dual-eligible, Medicaid might pay the Part B premium.
To find Medicare Advantage plans in your vicinity, you can start anytime by clicking the Browse Plans button on this page.
Medicare information is everywhere. What is hard is knowing which information to trust. Because eHealthâs Medicare related content is compliant with CMS regulations, you can rest assured youâre getting accurate information so you can make the right decisions for your coverage.Read more to learn about our Compliance Program.
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.
- Whats the difference between these two government health insurance programs?
- What exactly are Medicaid and Medicare?
- Whos eligible to get Medicaid or to get Medicare?
- And how can some people get both?
Read on to find out the answers to these questions and more.
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Millions Under Expanded Medicaid Will Transition To Medicare
There are currently almost 20 million people covered under expanded Medicaid, accounting for almost a quarter of all Medicaid enrollees nationwide. Under ACA rules, there are no asset limitations for Medicaid eligibility for pregnant women, children, or adults eligible due to Medicaid expansion. Instead, eligibility is just based on an ACA-specific version of modified adjusted gross income , along with immigration status.
But Medicaid expansion and the MAGI-based eligibility rules only apply to adults under the age of 65. After that, expanded Medicaid is no longer available. To be clear, Medicaid remains available after age 65 and many older adults rely on it for example, the majority of nursing home residents in the United States have Medicaid coverage in addition to their Medicare coverage.
But once you turn 65, eligibility for Medicaid is based on both income and assets. Theres some variation from one state to another , but in general, the income limits are lower than those that apply to the Medicaid expansion population, and the asset limits are quite restrictive.
This can lead to some sticker shock for people who were eligible for expanded Medicaid prior to turning 65, but then have to transition to Medicare possibly without eligibility for any further Medicaid assistance once they turn 65.
Medicare And Medicaid Whats The Difference Are They State Or Federal Programs
Before we get into Medicare Advantage vs. Medicaid, here are some brief basics on Medicare and Medicaid.
Medicare and Medicaid have the same âparentâ agency: the Centers for Medicare & Medicaid Services.
As you might already know, Medicare is a government health insurance program. Itâs mainly for people aged 65 or older, but some people qualify by disability before age 65. âOriginal Medicareâ is made up of Medicare Part A and Part B .
Medicare has four parts:
- Part A: Helps pay for hospitalization costs
- Part B: Helps pay 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 to provide at least the same benefits as Original Medicare Part A and Part B .
- Part D: Stand-alone Medicare Part D prescription drug plans and Medicare Advantage prescription drug plans offered by private companies approved by Medicare to assist with the cost of prescription drugs.
Medicaid is also a government health insurance program, but those who qualify generally have low incomes or disabilities, and donât have to be over 65 years old. Medicaid is administered by the states, but must follow certain federal rules.
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Medicare Part B Enrollment And Penalties
Medicare Part B is optional, but in some ways, it can feel mandatory, because there are penalties associated with delayed enrollment. As discussed later, you dont have to enroll in Part B, particularly if youre still working when you reach age 65.
However, if you dont qualify for a Special Enrollment Period , then you may incur penalty charges. These penalty charges are indefinite for as long as you keep Medicare Part B. When should you enroll in Medicare Part B? If youre not automatically enrolled because of the aforementioned conditions, then here are your enrollment options:
- You have a seven-month initial period to enroll in Medicare Part B. The seven months include the three months prior to your 65th birthday, the month containing your 65th birthday and the three months that follow your birthday month. If you turn 65 on March 8, then you have from December 1 to June 30 to enroll in Medicare Part B.
- If you delay enrollment, then you have to wait until the next general enrollment period begins. For Medicare Part B, you have from January 1 through March 31 to enroll. Coverage doesnt begin until July.
Can I Decline Medicare Altogether
Medicare isnt exactly mandatory, but it can be complicated to decline. Late enrollment comes with penalties, and some parts of the program are optional to add, like Medicare parts C and D. Medicare parts A and B are the foundation of Medicare, though, and to decline these comes with consequences.
The Social Security Administration oversees the Medicare program and recommends signing up for Medicare when you are initially eligible, even if you dont plan to retire or use your benefits right away. The exception is when you are still participating in an employer-based health plan, in which case you can sign up for Medicare late, usually without penalty.
While you can decline Medicare altogether, Part A at the very least is premium-free for most people, and wont cost you anything if you elect not to use it. Declining your Medicare Part A and Part B benefits completely is possible, but you are required to withdraw from all of your monthly benefits to do so. This means you can no longer receive Social Security or RRB benefits and must repay anything you have already received when you withdraw from the program.
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