Many seniors and disabled individuals are eligible for both Medicare and Medicaid benefits based on their income and the severity of their disabilities. This article directs you to resources that will help you determine which, if any, of those benefits you quality for.
Medicare and Medicaid have been around for more than half a century. President Lyndon B. Johnson signed into law the bill that created Medicare and Medicaid on July 30, 1965. At that time, Medicare consisted of Part A (hospital insurance) and Part B (outpatient medical insurance). Today these together are often referred to as Original Medicare. Neither Medicare nor Medicaid has remained static over the years, as Congress has passed many changes to both programs.
Starting in 1972, Medicare was expanded to not just cover people over age 65, but also to cover disabled people and people with end-stage renal (kidney) disease that requires dialysis or transplant. In 2003, an optional prescription drug benefit was added to Medicare. After originally being designed for people receiving cash assistance, Medicaid now covers many groups, including low-income families, pregnant women, disabled people, and people who need long-term care. Medicare is administered on a federal level, while Medicaid is administered by the states. Therefore, Medicaid programs may vary in terms of services from one state to another.
Medicare Deductibles and Premiums
Many people, upon approaching age 65 and Medicare eligibility, are surprised to discover that Medicare has deductibles, premiums, and co-insurance responsibilities. Medicare offers comprehensive healthcare services, but Medicare Part A (hospital insurance) includes a deductible of almost $1,350, and hospital stays of longer than 60 days require enrollees to pay some co-insurance costs. As for Medicare Part B (outpatient care), it also has deductible and co-insurance costs, and most enrollees pay a monthly premium of just over $130.
So, what are people to do if they cannot cover those deductibles, co-insurance payments, and premiums? Many of them may be eligible for Medicaid as well as Medicare, in which case Medicaid would pay the monthly premium and other out-of-pocket Medicare costs. When a person has both Medicare and Medicaid, he or she has “dual coverage,” or is considered a “dual enrollee.”
People over 65 also have the choice of forgoing original Medicare in favor of what’s known as Medicare Part C, or “Medicare Advantage” plans. These are authorized private insurers that administer Medicare benefits, and premiums, deductibles, and restrictions vary. Some seniors find that they benefit more from a Medicare Advantage plan than from original Medicare.
Eligibility for Medicare
Most people qualify to receive Medicare when they turn 65. Specifically, eligibility begins at 65 for people who are U.S. citizens or legal residents, who have lived in the United States for at least five years, and who have worked at least 10 years in Medicare-eligible employment. So if this is you, and you have had Social Security taken from your paychecks over the years, you will most likely receive a Medicare card in the mail shortly before you turn 65. This packet will outline the benefits of Part A and Part B. Though most people with Part A coverage choose to also have Part B coverage, Part B is actually optional.
As for people under age 65, qualification for Medicare results from having end-stage renal disease, or from having received Social Security Disability Income (SSDI) payments for 24 months. People under age 65 who have amyotrophic lateral sclerosis (ALS, also called Lou Gehrig’s Disease) qualify for Medicare during their first month of disability. Medicare covers a lot, but it doesn’t cover everything, and out-of-pocket costs can be a challenge for many people to meet.
Eligibility for Medicaid
Medicaid and the Children’s Health Insurance Program (CHIP) cover almost 60 million Americans. Eligible for Medicaid are children, pregnant women, senior citizens, and individuals with disabilities. To participate in Medicaid, states are required to cover certain mandatory eligibility groups, but they have some flexibility in who else to cover (optional eligibility groups). Each state sets Medicaid eligibility criteria within federal boundaries, and states are allowed to apply to the Center for Medicare and Medicaid Studies (CMS) for a waiver of the federal law expanding coverage beyond these groups. States that do not apply for waivers for coverage expansion are known as “Medicaid expansion states.”
Medicaid qualification is based on income as a percentage of the federal poverty level. As of 2018, the federal poverty level for a family of four was $25,100, for example. This figure is updated every year. Some people qualify for Medicaid coverage based on income or non-financial standards for programs such as the Supplemental Security Income program.
Eligibility for Dual Enrollment
“Dual eligibility” means that a person qualifies for both Medicare and Medicaid. These people are enrolled in Medicare Part A (and often Part B), plus they receive full Medicaid benefits and assistance with Medicare premiums or cost-sharing through one of a number of programs. For example, a Qualified Medicare Beneficiary Program helps pay for premiums for Medicare Parts A and B, deductibles, co-payments, and co-insurance responsibilities. Other programs that cover dual eligibility include the Specified Low-Income Medicare Beneficiary (SLMB) Program and the Qualifying Individual (QI) Program, which help pay for Part B premiums, and the Qualified Disabled Working Individual (QDWI) Program, which pays Part A premiums for certain working, disabled people.
The Challenge of Coordinating Benefits
If a person qualifies for both Medicaid and Medicare, who pays first? Whenever a Medicare-covered service is also covered by Medicaid, then Medicare pays first. Medicaid may cover the costs that Medicare either doesn’t cover, or only partially covers. These are services like nursing home care, community-based services, and personal care services. Exactly how Medicaid benefits are distributed is determined by each state. For example, some states administer Medicaid through managed care plans, while others provide Medicaid reimbursement on a fee-for-service basis.
In some states, plans are available to cover both Medicare and Medicaid benefits. Because coordinating Medicare and Medicaid benefits can be tricky, there are organizations that help dual enrollees to understand their benefits. For those who cannot cover both Medicare and Medicaid under a single policy, health centers and other community organizations can assist with case management. This can alleviate some of the burden of submitting paperwork and coordinating benefits, which can be complex and demanding.
Dual Eligibility Rises with Age
Sometimes people reach age 65 and qualify for Medicare but do not qualify for Medicaid. However, eligibility for Medicaid can be reassessed periodically. It’s not unusual for retirees to “spend down” their assets until such a point that they qualify for Medicaid to help with Medicare costs.
Medicare and Medicaid are social safety net programs designed to help the most vulnerable populations receive healthcare. A person may qualify for Medicare only, Medicaid only, or may qualify for both, depending on age, disability, and income. Each state offers online resources for those eligible for Medicare and Medicaid so they can better understand their eligibility and coverage options.
With the cost of healthcare continuing to increase at a faster pace than general inflation, seniors and others with low incomes may find that they qualify for more help than they realize toward paying for healthcare coverage. eDrugstore.com is committed to educating consumers about important health topics like Medicare and Medicaid, and it invites you to browse its blog for more helpful content.
We specialize in providing our over 1,000,000 customers with relevant product and condition information created by our professional editorial staff which includes our team of medical writers, medical practitioners, and health educators. eDrugStore.com Staff on Facebook