Who Can Get Obamacare Coverage
If youâre a legal resident of the United States, you can buy an Obamacare private health insurance plan through your states ACA health insurance exchange as long as youâre not enrolled in Medicare.
Subsidy eligibility: If your household income is in the subsidy-eligible range and youre not eligible for Medicaid, Medicare, or an employer-sponsored plan that provides affordable, comprehensive coverage, you may qualify for a subsidy that helps pay part of your monthly health insurance premiums.
For several years, subsidy eligibility had an income cap equal to 400% of the federal poverty level. But that income cap was eliminated for 2021 and 2022, under the American Rescue Plan. The Build Back Better Act, under consideration in Congress in late 2021, would extend that provision through 2025.
Expanded Medicaid exception: Under the ACA, your household income has to be at least 100% of the poverty level in order to qualify for a premium subsidy. But subsidies are not available if youre eligible for Medicaid, and in states that have expanded Medicaid under the ACA, Medicaid is available to people with income up to 138% of the poverty level. So the lower threshold for ACA subsidy eligibility is 139% of the poverty level in those states. As of 2021, Medicaid has been expanded in 38 states and DC, so the lower eligibility level for premium subsidy eligibility is 139% of the poverty level in the majority of the country.
Can You Have Both Medicare And Medicaid
Some people who receive Medicare coverage also qualify for Medicaid. They are considered dual eligible, says Heather Sanderson, a Medicare secondary compliance expert in Palmetto, Florida. A lot of dual-eligible beneficiaries are senior citizens who have a low income. With some plans, Medicaid coverage helps pay Medicare premiums and out-of-pocket costs like deductibles and coinsurance.
Medicare Advantage also offers Special Needs Plans for people who are dual-eligible. These SNPs offer services and provider networks tailored to specific needs.
Whats The Difference Between Medicare And Medicaid
Medicare is a federal government health insurance program for qualified people 65 years old and above, or those who qualify by disability. Medicaid is a government program paid for by both state and federal government funds. Eligible people with disabilities or low incomes may get health coverage through Medicaid.
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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
How Can Des Help Me
The DES State Health Insurance Assistance Program is a free health benefits counseling service for beneficiaries. Through education, outreach, counseling and training, SHIP helps individuals make informed health insurance decisions that optimize access to care and benefits.
The Medicare Open Enrollment period begins October 15. Its not too early to research which plan is right for you!
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Apply For Medicaid Coverage Even If Your State Hasnt Expanded
Even if your state hasn’t expanded Medicaid and it looks like your income is below the level to qualify for financial help with a Marketplace plan, you should fill out a Marketplace application.
Each state has coverage options that could work for you particularly if you have children, are pregnant, or have a disability. And when you provide more detailed income information you may fall into the range to save.
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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How To Choose The Right Health Care Coverage For You
Although you may be eligible for both programs, in some cases, you might be in a position to choose between Medicare and Medicaid.
If youre eligible for Medicare, you have to choose between Original Medicare or Medicare Advantage, based on your preferences. But how do you decide? Take a look at some of the key differences.
Medicaid Coverage Vs Medicare Coverage
Medicaid is for low-income families, so there are virtually none when it comes to copayments. While families may have to select a managed care plan through a private insurance provider, there are no in-network copayments.
Medicaid networks are strict, but they cover the entire bill. You can expect inpatient and outpatient services, lab tests, x-rays, home health, prescriptions, therapy, and more to be covered by Medicaid. Also, Long-term care and nursing homes have coverage through Medicaid.
Original Medicare only covers 80% of your medical bills after deductibles are met. Medicare will cover inpatient and outpatient services, including lab tests, X-rays, therapy, and more. However, Medicare wont cover doctor prescriptions for medications you take daily at home, long-term care, or nursing home care.
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Which Program Applies To You
It should be easy to know which one you qualify for mostly dependent on your income. It is also possible to qualify for both. You are dual eligible if you qualify for Medicaid by the means test and for Medicare Part A and/or Part B by age or disability.Many states run Medicare Savings Programs and if you are dual eligible you may qualify for benefits through this program. MSP will take care of premiums, copays, and deductibles to further reduce your costs. It will vary based on income, but some people will receive all out of pocket expense paid. These people are considered Full Benefit Dual Eligible . Persons in an MSP automatically receive Medicare Extra Help eliminating most if not all prescription copays..
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Medicare Price Changes In : Part B Premiums Are Getting Cheaper
Medicare premium costs are changing next year. Well explain how much.
Katie Teague
Writer
Katie is a writer covering all things how-to at CNET, with a focus on Social Security and notable events. When shes not writing, she enjoys playing in golf scrambles, practicing yoga and spending time on the lake.
In 2023, Medicare Part B premium prices will be cheaper, while Part A premiums and deductibles are getting slightly more expensive. This is because the Social Security Administration each year adjusts costs associated with the Medicare program by raising or lowering premiums and deductibles using rules set out in the Social Security Act.
The income brackets and amounts for adjustments to Part D prescription drug coverage have also been slightly revised. Additionally, if you receive Social Security payments, the cost-of-living benefits increase for 2023 has been announced. This means that seniors will have a chance to get ahead of inflation, due to the rare combination of rising benefits and falling premiums,press secretary Karine Jean-Pierre said during a White House briefing.
Heres how much the prices will go down for those who receive Medicare Part B and what the new costs will be next year. Note: The open enrollment period for Medicare ends Dec. 7.
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Medicaid Through Private Companies
Although Medicaid is a government program, in most states, Medicaid services for the majority of enrollees are provided through a private health insurance company.
If you receive a Medicaid ID card from UnitedHealthcare, Humana, Kaiser, or Blue Cross, you might mistakenly assume youâre receiving private Obamacare health insurance, when itâs actually just the company your state has contracted with to provide Medicaid benefits.
Even though a private company is managing the Medicaid coverage, the benefits themselves are still Medicaid and the money to pay for those benefits ultimately comes from federal and state taxpayer funds.
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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.
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What Medicaid Helps Pay For
If you have Medicare and qualify for full Medicaid coverage:
- Your state will pay your Medicare Part B monthly premiums.
- Depending on the level of Medicaid you qualify for, your state might pay for:
- Your share of Medicare costs, like deductibles, coinsurance, and copayments.
- Part A premiums, if you have to pay a premium for that coverage.
What Do The Different Medicare Components Cover
Medicare has three different components, and every recipient isnt necessarily entitled to use all of them:
- Hospital: Medicare Part A provides hospitalization coverage as well as paying some hospice, nursing home and home health care costs.
- Medical: Medicare Part B works like most private insurance policies and covers doctors visits, lab work, and visits to the emergency room.
- Prescription Drugs: Medicare Part D helps cover prescribed medication costs. Medicare Part A and B participants are eligible for Part D .
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Medicaid Is Structured As A Federal
Subject to federal standards, states administer Medicaid programs and have flexibility to determine covered populations, covered services, health care delivery models, and methods for paying physicians and hospitals. States can also obtain Section 1115 waivers to test and implement approaches that differ from what is required by federal statute but that the Secretary of HHS determines advance program objectives. Because of this flexibility, there is significant variation across state Medicaid programs.
The Medicaid entitlement is based on two guarantees: first, all Americans who meet Medicaid eligibility requirements are guaranteed coverage, and second, states are guaranteed federal matching dollars without a cap for qualified services provided to eligible enrollees. The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for poorer states .
Figure 2: The basic foundations of Medicaid are related to the entitlement and the federal-state partnership.
Medicare Vs Medicaid: Which Healthcare Plan Covers Ssi Recipients
Getting Medicare vs Medicaid coverage depends on which government assistance program provides your monthly disability checks. If youre getting SSI benefits, youre also automatically enrolled in the Medicaid program unless you live in:
- Northern Mariana Islands
If you reside in an automatic-enrollment state, theres no waiting period for Medicaid coverage. SSI beneficiaries living in one of the states or territories listed above must submit a separate Medicaid application.
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Already Enrolled In Medicare
If you have Medicare, you can get information and services online. Find out how to .
If you are enrolled in Medicare Part A and you want to sign up for Part B, please complete form CMS-40B, Application for Enrollment in Medicare Part B . If you are applying for Medicare Part B due to a loss of employment or group health coverage, you will also need to complete form CMS-L564, Request for Employment Information.
You can use one of the following options to submit your enrollment request under the Special Enrollment Period:
Note: When completing the forms CMS-40B and CMS-L564:
- State I want Part B coverage to begin in the remarks section of the CMS-40B form or online application.
- If possible, your employer should complete Section B.
- If your employer is unable to complete Section B, please complete that portion as best as you can on their behalf and submit one of the following forms of secondary evidence:
- Income tax form that shows health insurance premiums paid.
- W-2s reflecting pre-tax medical contributions.
- Pay stubs that reflect health insurance premium deductions.
- Health insurance cards with a policy effective date.
- Explanations of benefits paid by the GHP or LGHP.
- Statements or receipts that reflect payment of health insurance premiums.
Some people with limited resources and income may also be able to get .
Dual Eligibility: What If You Qualify For Both Medicare And Medicaid
In some cases, you may be eligible for coverage under both Medicare and Medicaid. This is called dual or dual eligible. There are Medicare Advantage plans specifically available for people who are eligible for both Medicare and Medicaid theyre called Dual Special Needs plans, or DSNPs. DSNPs often cover benefits not offered by Medicare, such as routine hearing, vision and dental coverage. Theyre available to dual-eligible beneficiaries, but so are other Medicare Advantage plans or just Original Medicare plus Medicaid.
Some dual eligible Medicare beneficiaries are eligible for full Medicaid benefits, while others are eligible for Medicaid-funded benefits that help to cover their Medicare premiums and cost-sharing. You can learn more about dual eligibility in this booklet from the Centers for Medicare and Medicaid Services.
- In part by the Medicare payroll tax
- In part by Medicare recipients premiums
- In part by general federal taxes
The Medicare payroll taxes and premiums go into the Medicare Trust Fund. Bills for healthcare services to Medicare recipients are paid from that fund.
Medicaid is:
- Partially funded by the federal government
- Partially funded by each state
The federal government pays an average of about 60% of total Medicaid costs, but the percentage per state ranges from 50% to about 78%, depending on the average income of the stateâs residents .
Under the ACAâs expansion of Medicaid, however, the federal government pays a much larger share.
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If Your Income Is Low And Your State Hasnt Expanded Medicaid
If your state hasnt expanded Medicaid, your income is below the federal poverty level, and you don’t qualify for Medicaid under your state’s current rules, you wont qualify for either health insurance savings program: Medicaid coverage or savings on a private health plan bought through the Marketplace.
- Find out why
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- When the health care law was passed, it required states to provide Medicaid coverage for all adults 18 to 65 with incomes up to 133% of the federal poverty level, regardless of their age, family status, or health.
- The law also provides premium tax credits for people with incomes between 100% and 400% of the federal poverty level to buy private insurance plans in the Health Insurance Marketplace®.
- The U.S. Supreme Court later ruled that the Medicaid expansion is voluntary with states. As a result, some states havent expanded their Medicaid programs.
- Adults in those states with incomes below 100% of the federal poverty level, and who dont qualify for Medicaid based on disability, age, or other factors, fall into a gap.
- Their incomes are too high to qualify for Medicaid in their states.
- Their incomes are below the range the law set for savings on a Marketplace insurance plan.
-
States are continuing to make coverage decisions. They could expand Medicaid in the future.
A Birthday Wish For Medicare And Medicaid: Less Waste And Better Care
President Lyndon B. Johnson signs the Medicare bill as Vice President Humphrey and Harry S. Truman both check the time.
Bettmann Archive
This Saturday, July 30, marked 57 years since President Lyndon B. Johnson signed Medicare and Medicaid into law as part of his Great Society.
For almost six decades, the healthcare entitlements have grown increasingly costly and expansive while delivering subpar care to beneficiaries.
Consider Medicare, the health plan for Americans 65 and older as well as some people with disabilities. Many seniors believe that Medicare is free once they retire. They paid thousands in taxes to Medicare over the course of their careers. Now they get the payoff, right?
Wrong. Each year, the average beneficiary spends more than $6,000 on premiums, out-of-pocket costs, and supplemental insurance that covers various services Medicare doesnt.
Those costs have steadily increased in recent years. According to the Kaiser Family Foundation, the combined cost of Medicare deductibles and premiums is equal to nearly 20% of the average Social Security benefit â up from just 15% 20 years ago.
Taxpayers are paying more for Medicare, too. Spending on the entitlement increased more than two percentage points faster than GDP between 1980 and 2010. Today, Medicare accounts for one of every five dollars the United States spends on health care âroughly $830 billion in 2020.
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