Dual-Eligible Medicare And Medicaid: What Are The Differences, Eligibility Criteria, And Premiums? 

Dual-Eligible Medicare And Medicaid: What Are The Differences, Eligibility Criteria, And Premiums? 

What are Dual-Eligible Medicare and Medicaid programs? After signing amendments to the Social Security Act on July 30, 1965, President Lyndon B. Johnson introduced Medicare and Medicaid programs. The Centres for Medicare and Medicaid Services (CMS), considered a division of the United States Department of Health and Human Services (HHS), manages both programs.

According to Medicaid.gov, approximately more than 12 million people in the U.S are dually eligible for these programs. Since November 2019, Medicaid has served nearly 64.5 million people, and Medicare has covered healthcare expenses for around 58 million beneficiaries. 

Government supports and provides funding to Medicare and Medicaid programs to share the financial burden of the people with lower income to help them get health equity and resources.

Commonly, people get confused between these two terms. Therefore, it’s essential to discover how these programs work during the dual-eligibility period to offer benefits.

Medicare and Medicaid are in place to cover medical and healthcare expenses, including drug prescriptions, in-patient, outpatient facilities, and doctor’s visits.

Before discussing these programs in detail, let’s understand their differences:

What Is Medicare Program?

Medicare is a federal insurance program with no financial restrictions. It’s designed for people older than 60 years and disabled persons to receive healthcare services. A beneficiary must meet the eligibility criteria based on spouse or employment history to enroll in Medicare. 

Primarily, Medicare is classified into four basic components called Part A, Part B, Part C, and Part D Medicare. During enrollment, beneficiaries can choose Part A and Part B benefits with an optional Part D plan to get healthcare facilities.

Furthermore, they can also select a stand-alone plan called MAPD. A beneficiary can acquire additional benefits with several drug prescription plans. Above all, Medicare also offers savings programs to fulfill basic to specific healthcare needs.

Eligibility Standards For Medicare

Usually, people who turned or will soon turn 65 years old can easily apply for the Medicare program. A beneficiary receives premium-free Part A (hospital coverage) services and benefits only if he is 65 years old and has paid Medicare taxes during his employment. Moreover, you can also enroll in Part B (medical coverage), which covers medical expenses for doctor visits.

Who Gives Financial Support To Medicare?

Medicare gets its funding from:

  • the Self-Employment Contributions Act (SECA)
  • payroll taxes under the Federal Insurance Contributions Act (FICA)

Usually, employees and employers contribute equally to pay these taxes. The taxes amount altogether goes into the trust fund so that government can reimburse private and insurance companies. Even more, deductibles, premiums, coinsurance, and copays also become the additional funding source for Medicare.

What Is Medicaid Program?

Medicaid is a joint state and federal healthcare assistance program introduced for people of all ages with low income. Each state operates its own program by following rules, policies, statuses, and national federal guidelines. The state includes job roles like:

  • Determining type, scope, duration, and amount for the offered services.
  • Setting eligibility standards.
  • Establishing premiums, copays, coinsurance, and deductibles for the services.

Familiarity With ‘Medicaid Spenddown’

Are you familiar with the term ‘Medicaid Spenddown’? In some states, to meet eligibility criteria for Medicaid, a beneficiary must spend some amount from his income to fall under Federal Poverty Level. However, FPL may vary based on the family size. Therefore, you must show lower-income status to qualify for Medicaid.

Eligibility Standards For Medicaid

The eligibility standards for Medicaid vary geographically in each state. In addition, eligibility criteria may change every year, so if you might not qualify for the current year, there are slight chances for you to qualify in the next year. Some of the other eligibility standards considered by states are:

  • Citizenship
  • Status of disability
  • Status of pregnancy
  • Age and assets

Who Gives Financial Support To Medicaid?

Medicaid directly submits payments to the healthcare providers rather than paying to the individuals. Institutions like HMOs receive payments from the states according to a fee-for-service agreement or through prepayment services. Later, the federal government reimburses a certain percentage of Medicaid expenses.

You must remember that FMAP modifies every year and depends on the state’s income level. Therefore, states with less income receive more reimbursement than those with higher income.

Services Covered Under Medicaid Program

Following are the services that states must offer through their Medicaid Program:

  • Mental health services
  • Doctor visits
  • Prescription drugs
  • Inpatient and outpatient hospital services
  • Family planning service
  • Prenatal care
  • Maternity care
  • Preventive care, including immunizations, colonoscopies, and mammograms

Some of the additional services that the state may cover:

  • Vision and eyeglasses
  • Physical therapy
  • Dental services
  • Prosthetic devices
  • Home and community-based services

Children who’re dual eligible beneficiaries can get services like hearing, dental, vision, and many other facilities through Medicaid Early Periodic Screening, Treatment (EPSDT), and diagnostic benefits.

What Is Full Medicaid Coverage?

Full Medicaid covers a certain package of services beyond Medicare cost-sharing and premiums that beneficiaries use when they qualify for the state’s Medicaid Program consisting of different eligibility groups. Some of the groups that the state covers:

  • Supplemental Security Income [SSI] recipients
  • Special income level institutionalized beneficiary group
  • Home- and community-based waiver participants
  • Medically needy individuals

How to qualify for Full Medicaid Coverage?

To qualify for Full Medicaid coverage, a beneficiary must meet medical criteria set by the state. Furthermore, the state pays for Full Medicaid when a beneficiary is enrolled in Part A and Part B. However, the cost structure may vary according to the federal guidelines, and the state has the right to assess income and resource limits to meet eligibility standards.

How Does Dual-Eligible Medicare and Medicaid Work?

Besides enrolling in the Original Medicare, a beneficiary can also get benefits from full Medicaid.

You might be thinking, how? Here’s how it works:

Dual-eligible beneficiaries are often called low-income beneficiaries enrolled in both Medicaid and Medicare. When a beneficiary has both Medicare and Full Medicaid coverage, most of his expenses for healthcare got covered. Together, Original Medicare and Medicare Advantage Plan give Medicare coverage to beneficiaries to a great extent. Meanwhile, you also get Part D coverage when enrolled in Medicare and Full Medicaid. A beneficiary automatically gets Extra Help to cover Part D expenses during the dual-eligibility period.

Note: Medicaid offers services and medication that are sometimes not offered in Medicare. Therefore, people prefer to get dual enrollment in both programs. 

In other circumstances, a dual-eligible period starts when an enrollee gets aid from the Medicare premiums or the cost-sharing Medicare saving plans. Some of the Medicare Savings Programs are mentioned below:

Qualified Medicare Beneficiary (QMB) Program

In this program, a beneficiary gets medical coverage of Part A and Part B premiums and shares the expenses of low-income Medicare beneficiaries. According to federal law, QMB beneficiaries don’t have any legal obligations against paying bills, deductibles, premiums, and copays for any Medicare service.

Individual Monthly Income Individual-Resource LimitMarried Couple Monthly IncomeMarried Couple Resource Limit

Specified Low-Income Medicare Beneficiary (SLMB) Program

In the SLMB program, a beneficiary expects the state to share his Medicare premiums. Additionally, it covers Part B premiums and gives full Medicaid coverage too.

SLMB plan for income and resources limit in 2022:

Individual Monthly Income Individual-Resource LimitMarried Couple Monthly IncomeMarried Couple Resource Limit

Qualifying Individual (QI) Program

It’s a state program that helps cover only Part B premiums for beneficiaries already enrolled in Part A and have lower income resources. Furthermore, the benefits of QI are limited to first-come-first-served applications. However, you can’t get QI benefits if you meet the eligibility criteria for Medicaid.

QI plans for income and resources limit in 2022:

Individual Monthly Income Individual-Resource LimitMarried Couple Monthly IncomeMarried Couple Resource Limit

Qualified Disabled Working Individual (QDWI)

QDWI program helps cover Part A premium and can qualify for this program if all of the conditions mentioned below apply to your case:

  • You’re an employee
  • Disability
  • When you lost your premium-free Part A and Social Security Disability benefits while returning to work.
Individual Monthly Income Individual-Resource LimitMarried Couple Monthly IncomeMarried Couple Resource Limit

List Of Resource Limits In The Medicare Saving Programs

You should know about the list of resource limits that fall in the Medicare Saving Programs. As a result, it will help you determine how close you’re to meeting the eligibility criteria for the Saving Programs.

List Of Countable Items:

  • Stocks
  • Money in a checking or savings account
  • Bonds

List Of Uncountable Items:

  • $1,500 for burial expenses
  • Your home
  • One car
  • Burial plot
  • Other personal and household items
  • Furniture

Who Pays First For The Healthcare Services?

Medicare bears all the healthcare expenses in the first place. However, what is left on the table is usually covered by Medicaid. However, each state sets a limit for the amount paid by Medicaid. Furthermore, it pays after employer group health plans, Medigap, and after Medicare covers all the services except the ones that aren’t covered in it.

In special situations, when you qualify for the QMB program: Medicaid covers your Medicare services cost, including deductibles, coinsurance, copays, Part A premium, and Part B premium. In addition, it continues to pay even when Medicaid doesn’t cover Medicare services or the healthcare providers who don’t accept Medicaid.

What Are The Benefits Of Dual Eligibility Of Medicare And Medicaid?

A beneficiary hardly looks for more options if he gets healthcare coverage with lower out-of-pocket costs in one package. Dual-eligibility of Medicare and Medicaid gives full-fledged recovery for the healthcare needs.

Medicare covers all your healthcare expenses as the first payer and lets Medicaid becomes the second payer for the services that aren’t covered in Medicare. For instance, services like personal care assistance in the community or home and long-term skilled nursing home care.

However, Medicare Advantage Plan is an exception that sometimes covers long-term care and support. Below, you’ll find the list of long-term benefits covered by Medicaid that are sometimes covered in the MAP as well;

  • Scheduling and delivering meals to the patients
  • Adult daycare
  • Transportation facility for medical and non-medical purposes
  • Getting personal care assistance at home and in adult foster care homes with assisted living facilities.
  • Home skilled nursing
  • Respite care
  • Personal emergency response systems
  • Core services or housekeeping
  • Additional therapies (occupational, physical, and speech)
  • Medication administration

Note: Both Medicaid and Medicare will provide the beneficiaries with essential medical equipment, including wheelchairs and walkers.

Ready To Find The Best Dual-Eligible Medicare And Medicaid Plan? Let STL Medicare Benefits Be Your Guide.

How will you know when you’ve become dual-eligible for Medicare and Medicaid? STL Medicare Benefits updates you about the enrollment period by comparing the best plans to suit your healthcare needs.

Most beneficiaries are unaware of dual-eligibility standards and how to initialize them during enrollment in Medicare. In this regard, we guide our clients through Medicare and Medicaid plans.

What else do we do as your guide?

We try our best to get maximum benefits at your end when you’re enrolled in Medicare and help you become dual-eligible with the proper assistance. STL Medicare Benefits services extend to:

  • Receiving and delivering information regarding Full Medicaid Benefits.
  • We guide you about Medicare Premiums and methods to cover them during enrollment.
  • Educating you about Medicare Savings Program and its role in the dual-eligibility period.

Have more questions about dual-eligible Medicare and Medicaid plans? Let’s meet to discuss better options for your healthcare needs.

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