Medicare And Medicaid Dual Eligibility Requirements

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How Much Does Medicare Cost

Medicare vs. Medicaid | Mnemonic for USMLE

Medicare costs depend on which parts youre enrolled in and how long you worked and paid Medicare taxes.

For 2023, the monthly premiums are:

  • Part A: $0 if you paid Medicare taxes long enough while working . Either $278 or $506 per month if you dont qualify for premium-free Part A, depending on how long you worked and paid Medicare taxes.

  • Part B: $164.90 or more per month, depending on your income.

  • Part C: Varies by plan

  • Part D: Varies depending on which plan you choose, but the average is around $43 per month

Important Information:

Like employer-sponsored health plans, Medicare has an open enrollment period. For Original Medicare, enrollment is from Oct. 15 to Dec. 7 each year. For Medicare Advantage, its Jan. 1 to March 31.

Check Out: The 10 Best & Worst Medicare Advantage Plans

What Is A Dual

Dual-eligible beneficiaries are also eligible for a certain type of Medicare Advantage plan called a Dual-Eligible Special Needs Plan .

Medicare Advantage plans, also known as Medicare Part C, are sold by private insurers. By law, they must provide all of the same basic coverage as Medicare Part A and Part B. Medicare Advantage plans may also offer additional benefits that Original Medicare doesnt cover, such as coverage for dental, vision, hearing aids, prescription drugs and more.

A Special Needs Plan is a specific type of Medicare Advantage plan that is designed for beneficiaries who have certain health conditions or financial circumstances. A Dual-Eligible Special Needs Plan contains coverage that is tailored for someone with low income and resources. Prescription drug coverage is automatically a part of D-SNPs.

You can browse Medicare plans online and compare any Medicare-Medicaid D-SNP plans that may be available where you live.

Long Term Care Benefits

Medicaid offers a wide range of long-term medical care benefits and supports, allowing people to age in place or in their community. Medicare does not provide these services, but in 2019, some Medicare Advantage plans began offering a variety of long-term home and community-based benefits. Long-term care benefits may include the following. This is not a complete list, and not all advantages may be available in all states.

  • Adult Day Health / Adult Day Care
  • Assistance with Personal Care
  • Transportation for Medical and Non-Medical Purposes
  • Care During a Break
  • Meal Delivery / Congregate Meals

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Dual Health Plans: What To Know

When someone is dually eligible, Medicare pays first for any covered services, and Medicaid pays after all Medicare and private health insurance benefits have been exhausted. As a result, they usually wont have any out-of-pocket healthcare costs.

While dual eligibility can provide access to more comprehensive coverage and lower out-of-pocket costs, there are also some potential drawbacks. For example, because Medicaid benefits vary by state, recipients may have difficulty navigating each programs rules and requirements.

Additionally, navigating the complex relationships between Medicare and Medicaid can be challenging, particularly if a provider or other service doesnt recognize both your coverage sources.

This article originally appeared on Insurify.com and was syndicated by MediaFeed.org.

Definition Of Dual Eligibility

Association of Dual Eligibility for Medicare and Medicaid With Heart ...

Individuals must be enlisted in Medicare Part A or Medicare Part B to be considered as dually eligible beneficiaries. People can choose Medicare Part C, also known as Medicare Advantage, as an alternative to Original Medicare Part A and B coverages. Moreover, participants in the Medicare Advantage program receive Medicare Part A, Part B, and, in some cases, Part D, which provides prescription drug coverage.

Furthermore, individuals must be enrolled in either a full-service Medicaid program or one of dual eligibility Medicaids Medicare Savings Programs . Medicaid full coverage includes hospital services , physician visits, laboratory facilities, and x-rays. Medicaid also covers nursing home care and, in many cases, limited personal care services in ones home. While some states provide long-term care and community supports through their state Medicaid program, many states offer these aids through 1915 Medicaid waivers.

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Who Are The Dually Eligible

The population of dually eligible beneficiaries is comprised of diverse subgroups. It includes: physically disabled, non-elderly beneficiaries cognitively impaired, non-elderly disabled Supplemental Security Income recipients who become Medicare-eligible after a 24-month waiting period frail elderly Medicare beneficiaries who have such high medical costs that they spend-down their income and assets to become Medicaid eligible and elderly beneficiaries who are low-income, but are not necessarily frail. Both non-elderly disabled beneficiaries, and Medicare’s oldest old-those 85 years of age or overare more likely to be dually eligible .

Murray and Shatto present results from the MCBS that show dually eligible beneficiaries are a particularly vulnerable population. By definition, they are poor, are more likely than Medicare-only beneficiaries to be from a minority population, unmarried, live alone, institutionalized, and nearly two-thirds did not graduate from high school. Dually eligible beneficiaries are also more likely to report significant and chronic health problems such as diabetes and heart disease. Significant service delivery and financing challenges arise in serving this population because they are also more likely to suffer from cognitive impairment, mental disorders, and limitations in their ability to perform daily activities, i.e., eating, walking, dressing, etc. .

Determining If You Are Eligible To Receive Both Medicare And Medicaid Coverage

The best way to determine if you are eligible to receive both Medicare and Medicaid coverage is to assess your individual situation. Consider your age, income level and current health needs to determine if you qualify for both programs. Additionally, its important to understand your rights and responsibilities when it comes to enrolling in both programs.

If you are unsure of your eligibility status, you can contact your local Area Agency on Aging or Medicaid office to get more information. They can provide guidance on the application process and answer any questions you may have.

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Financial Criteria To Qualify For Qmb+ Status

Maximum Monthly Income
Equals FMAP

What is Qualified Medicare Beneficiary Plus Status?

QMB+ is for people who have lower incomes than standard QMB individuals and qualify for full Medicaid cover. If you become a QMB+ beneficiary, you will receive full Medicaid benefits and be able to receive free or heavily subsidized medical services.

What does QMB+ status cover?

As a QMB+ you will receive full Medicaid benefits, and Medicaid will pay for your Medicare Part A and B premiums. Your Medicaid will also cover the costs of your Medicare deductibles and coinsurance amounts .

Financial Criteria To Qualify For Slmb+ Status

What Are Dual Special Needs Plans (D-SNP)?
Maximum Monthly Income
At 120% but lower than 135% Equals FMAP at 100%

What is a Qualified Individual status?

Qualified Individual status is for individuals who qualify as dual eligibles but aren’t in any of the above categories.

What does QI status cover?

Qi status means that Medicaid will only pay for your Medicare Part B premium. It will not cover Part A premiums and out-of-pocket expenses. It will not cover Part B deductibles and coinsurance costs.

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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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Dual Eligibility For Medicare And Medicaid: What It Means For You

The distinction between Medicare and Medicaid can be confusing. Because they sometimes both apply, it is important to have a firm understanding of both. Medicare and Medicaid dual eligibility can play a very important role in the services that you â or your loved one â receives, and having the professional legal counsel of an experienced Florida Medicaid planning attorney in your corner is paramount.

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Can You Have Both Medicare And Medicaid

In some cases, someone may be eligible for both Medicare and Medicaid at the same time. This is known as a dual eligibility status, or dually eligible for short.

Generally, this happens when someone qualifies for Medicare based on their age or disability status and Medicaid due to their financial circumstances.

Who Pays First If You Have Dual Eligibility

Does Medicaid Cover Home Health Physical Therapy

Since Medicaid is generally the payer of last resort, for dual eligible beneficiaries, Medicare pays covered medical services first.

If you have other coverage, such as employer group health plans or Medicare supplement plans , that coverage will pay first and Medicaid last.

Medicaid may cover healthcare costs that Medicare may not cover, or only partially covers, such as:

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Who Can Apply For Dual Eligibility

To qualify for dual eligibility, you need to meet the enrollment criteria for both the Medicare and Medicaid program.

To get Medicare coverage, you will need to be either:

  • 65, or turning 65 in the next three months.

  • Suffer from ESRD .

To get Medicaid coverage, you will need to:

  • Be a citizen or lawful permanent resident of the U.S.

  • Be a resident of the state in which you are receiving Medicaid coverage.

  • Pass a state-specific income and asset eligibility test to determine if you qualify.

Specific individuals are exempt from the income eligibility requirement. You can learn more about this by visiting the Medicaid.gov website.

If you meet both the Medicare and Medicaid enrollment criteria you will become dual eligible, and Medicaid will assist in covering the cost of your Medicare coverage.

Income and asset requirements are different for each state. Here are three examples to show you what these are in 2022 for different parts of the U.S.

Types Of Medicaid Coverage

Mandatory Medicaid benefits are mandated by the federal government. They include inpatient hospital services, laboratory services, outpatient services, and physician services.

Optional Medicaid coverage is state-specific and can include medical insurance for prescription drug coverage, dental services, occupational therapy, and hospice care.

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How Are Services Delivered

Medicare is available through either Original Medicare or various Medicare Advantage Plans . One type of Medicare Advantage plan, a dual eligible special needs plan , focuses on the specific healthcare requirements of this group.

Medicaid services vary by state. Medicaid may be available in the form of a managed care plan, fee-for-service or even a joint Medicare/Medicaid plan.

How Do I Enroll In Medicaid And Medicare Dual Eligible Plan

Dual Eligibility: Choice and Access for Individuals Eligible for Medicare and Medicaid, Judy Feder

If you are already a Medicaid beneficiary, to enroll in Medicaid and Medicare Dual Eligible plan, you must first contact your state Medicaid office. They will determine which level of Medicaid you currently have. Once you find this information out, contact MedicareInc.com and speak with a licensed Medicare insurance agent. You will be guided through which local insurance carriers offer this coverage and how to get signed up.

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Unitedhealthcare Connected For Mycare Ohio

UnitedHealthcare Connected® for MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected® for MyCare Ohio information, please contact our Member Services at from 7 a.m. to 8 p.m. Monday through Friday for help at no cost to you.

Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare Connected® de MyCare Ohio , comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al de lunes a viernes de 7 a.m. a 8 p.m. .

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays, and restrictions may apply. For more information, call UnitedHealthcare Connected Member Services or read the UnitedHealthcare Connected Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change from time to time throughout the year and on January 1 of each year.

Efforts To Integrate Medicare And Medicaid Benefits

Dual-eligibles typically receive their Medicare and Medicaid benefits through each program separately. For Medicare benefits, beneficiaries may opt to enroll in Medicare’s traditional fee-for-service program or in a private Medicare Advantage plan , which is administered by a Managed Care Organization , under contract with the Centers for Medicare & Medicaid Services , the agency in the Department of Health and Human Services that administers the Medicare program and oversees state Medicaid programs. In addition, dual-eligibles may choose a type of MA plan called a dual-eligible special needs plan , which is designed to target the needs of this population. For Medicaid benefits, beneficiaries generally enroll in their state’s Medicaid FFS program or a Medicaid managed care plan administered by an MCO under contract with the state.

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What Is The Difference Between Medicaid And Medicare

To be eligible for Medicare, the requirements are the same nationwide and are set by the federal government. The eligibility requirements are as follows:

  • You must be 65 years or older
  • Or, have a qualifying disability
  • You must be a U.S. citizen or permanent legal resident

Medicaid, on the other hand, varies from state to state. The federal government sets basic requirements for the program. Each state then determines additional eligibility standards. The purpose of Medicaid is to offer healthcare to people with low or no income.

Dual Eligible Beneficiaries Under Medicare And Medicaid

Medicare and Medicaid at 50: America

By Amy C. O`Hara, CELA

There are an estimated 11.4 million individuals receiving services through bothMedicare and Medicaid. These individuals, or dual eligible beneficiaries, are among some of the most vulnerable members of the patient population, due to a combination of low income and a high incidence of chronic health conditions. However, dual eligible beneficiaries face distinct challenges to receiving the services to which they are entitled.

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How Much Does Medicaid Cost

Most states dont charge premiums for Medicaid coverage. However, some states may require recipients to share in the costs of some services, such as nonpreventive doctor visits, nonemergency visits to an emergency room, inpatient hospital visits, and prescription medications.

Learn More: How to Switch Back to Medicare from Advantage Plans

Medicaid Eligibility Income Chart By State Updated Jul 2022

The table below shows Medicaids monthly income limits by state for seniors. Income is not the only eligibility factor for Medicaid long term care there is also an asset limit and level of care requirements. Additionally, there are state-specific details. Click on the state name below to see that states complete Medicaid eligibility criteria.

The maximum income limits change dependent on the marital status of the applicant, whether a spouse is also applying for Medicaid, and the type of Medicaid for which they are applying. Nursing home Medicaid may have a different income limit than home and community based Medicaid services, and both of those may differ from the Aged, Blind and Disabled income limits.

Exceeding the income limits does not mean an individual cannot qualify for Medicaid. Most states have multiple pathways to Medicaid eligibility, such as a medically needy pathway. Furthermore, many states allow the use of Miller Trusts or Qualified Income Trusts to help person who cannot afford their care costs to become Medicaid eligible. There are also Medicaid planning professionals that employ other complicated techniques to help persons become eligible. Finally, candidates can take advantage of spousal protection laws that allow income to be allocated to a non-applicant spouse.

Medicaid Eligibility Income Chart Updated July 2022
State

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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.

What Is Medicare Vs Medicaid

DSNP Clarity 2023 Video

Medicare

An animated white speech bubble appears over an animated character’s yellow and blue head.

ON SCREEN TEXT: Medicaid 101

The speech bubble and character fall away. Blue text appears on a light blue background. White text appears in two animated circles below. The blue and green circles overlap.

ON SCREEN TEXT: Medicaid is a joint federal and state health program. Federal State

The text and circles fall away. Blue text appears surrounded by blue animated disks with dollar signs on them. Animated individual and family character graphics appear below the text.

ON SCREEN TEXT: It is for individuals, families and children with limited income & resources.

The text and graphics fall away. A white map of the continental U.S. appears on a light blue background. Green map marker icons dot the map. Blue text appears in the center of the map.

ON SCREEN TEXT: Each state creates its own Medicaid programs based on federal guidelines.

The map disappears. Blue text appears surrounded by animated green and white form and plus sign graphics.

ON SCREEN TEXT: Medicaid programs have mandatory benefits & optional benefits.

The text and graphics fall away. Blue text appears over an animated dark blue scale graphic. Yellow animated coins pile up on the left side of the scale and animated books pile up on the right side.

ON SCREEN TEXT: Medicaid costs will vary based on a person’s income and the state’s Medicaid rules.

ON SCREEN TEXT: Eligibility varies based on a state’s Medicaid rules.

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