Medicare and Medicaid are two social health programs managed by the Centers for Medicare & Medicaid Services (CMS) to help senior, disabled, and low-income individuals afford needed health care coverage. The two services cover different sections of the population: Medicare helps seniors and the disabled while Medicaid assists the economically-stressed.
But what happens if you qualify for both? While you may be able to find a Medicare plan that suits your financial situation and medical needs, you may qualify for additional help. After all, many seniors are on a fixed income, which may allow them to have Medicaid coverage. Do you have to choose one over the other, or can you have both Medicare and Medicaid?
How Does Medicare and Medicaid Work Together?
Many seniors have what’s called dual eligibility for Medicare and Medicaid. Generally, this will mean that a beneficiary is enrolled in Original Medicare while receiving either full Medicaid benefits or help with Medicare costs. When you’re enrolled in both programs, Medicare will cover your medical service first. When paired with Medicare, Medicaid is considered a payer of last resort, meaning that it will cover things that Medicare doesn’t or only partially covers. Dual eligible benefits can vary from state to state, so check with your state’s Medicaid office for specifics.
When paired with Medicare, Medicaid is considered a payer of last resort, meaning it covers things that Medicare doesn’t fully cover.
Some health care services that Medicaid covers include dental care or behavioral health services for mental health care and substance abuse. Medicaid also offers cost-sharing measures to help cover out-of-pocket spending for those in need. It can even help with long-term care and prescription drugs. This can create comprehensive coverage for dual beneficiaries to help meet their health care needs.
One example of a Medicare/Medicaid coverage program is a Dual Eligible Special Needs Plan (D-SNP). Like other SNPs, D-SNPs are Medicare Advantage plans available to Americans with qualifying conditions, diseases, or characteristics. In this case, a D-SNP is available to seniors who qualify for both Medicare and Medicaid. While plans may differ by state, most D-SNPs offer a basic level of coverage and coordination between the two programs. D-SNPs can also have additional coverage for services like transportation, gym memberships, telehealth services, and dental, vision, and hearing benefits. Working with a licensed agent may help you find a D-SNP that’s available for your area.
Extra Help for Medicare Savings Programs
The most common form of dual eligible benefits is through Medicare Savings Programs (MSP) and Extra Help. Both sets of programs are simplified and focused coverage options through Medicaid. Instead of full Medicaid benefits, MSPs and Extra Help cover specific costs associated with Medicare. For MSPs, there are four different programs that cover different deductibles and costs associated with Original Medicare. These are the Qualified Medicare Beneficiary program, the Specified Low-Income Medicare Beneficiary program, Qualified Individual program, and the Qualified Disabled and Working Individuals program.
Instead of full Medicaid benefits, MSPs and Extra Help cover specific costs associated with Medicare.
Extra Help is a program that helps seniors afford prescription drugs. If you qualify for an MSP, you’re automatically enrolled in Extra Help. You can also enroll in Extra Help independent of enrollment in an MSP. Each program has their own income and resource limits that specify who qualifies for coverage. These can also vary by state.
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While Original Medicare was designed to be affordable and inclusive for seniors, most enrollees are still responsible for costs with their coverage. However, if your resources are already stretched thin, your dual eligibility can provide relief. Meeting with your local Medicaid office or speaking with a licensed sales agent can help you discover which option fits your needs best.
Centers for Medicare & Medicaid Services — Dual Eligible Beneficiaries Under Medicare and Medicaid
Henry J Kaiser Family Foundation — Medicaid’s Role for Medicare Beneficiaries