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Learn » Medicare » Dual Eligibility: Using Medicare and Medicaid at the Same Time

Dual Eligibility: Using Medicare and Medicaid at the Same Time

Dual-eligible status means that you can call on both Medicaid and Medicare to resolve your health needs.

December 5, 2018 - By Bud Scannavino - read

Researched by licensed + unbiased insurance experts. Learn More

Do you miss the paychecks from your working years? Well, there’s a bright side to any decline in income during old age. You might qualify for more health insurance than just Medicare alone. That extra coverage is free, and it’s called Medicaid.

If you have both Medicare and Medicaid coverage, then your status is called dual-eligible.

How much extra coverage would Medicaid give you? Your exact aid will be based on your financial need. If you qualify, you could receive either full-benefit Medicaid coverage or only partial-benefits. Keep in mind that whatever amount of help you receive will be in addition to your normal Medicare benefits.

This article will explain how Medicaid might work for you, the same way it works for millions of other people. You’ll also learn how to apply for those extra benefits.

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The Problem: Medicare Alone Will Cost You Money

Medicare is a great health insurance program, but it does have costs. You must pay your monthly Part B premium to stay enrolled in Medicare, plus your normal Medicare fees and charges. This frequently turns into copayments for medical services and prescriptions that add up beyond what many people can afford.

You could even wind up paying more than other folks for the same basic Medicare coverage, simply because extra coverage add-ons are out of reach.

The Solution: Medicaid Could Make Up the Medicare Difference for You

Some people think that Medicaid is welfare, but that is not true. Medicaid only covers medical expenses. Medicaid is a different program than Medicare.

Medicaid is for people whose incomes are close to the federal poverty line, or not very much above it. Today, Medicaid provides extra help paying doctor bills, hospital bills, and prescriptions (that’s big) for millions of Americans age 65 and over. If you fall into this category, then you’ll want to take a close look at your Medicaid eligibility.

Not Limited to Seniors: Other people besides seniors can receive Medicaid benefits as well. For example, certain people on disability and people with certain medical conditions can qualify for Medicaid at any age.

What Does “Dual-Eligible” Mean with Medicare?

In a nutshell, dual-eligible means you have both Medicare and Medicaid.

Dual-eligible status means that you can use both Medicaid and Medicare to cover your medical bills. Generally this entails Medicaid paying your out-of-pocket Medicare bills.

Medicaid Part A Payment Help: Most people receive Medicare Part A at no cost because they worked at least ten years before they turned 65 years of age. If you haven’t worked that much before age 65, you might qualify to purchase Part A. But that can cost hundreds of dollars each month. If you can’t afford that, it’s not out of reach! Medicaid might pay it for you.

Medicaid Part B Payment Help: Everybody must pay a Medicare Part B premium of about $135.50 monthly, regardless of how low their income is. What if you can’t afford that? If you qualify for Medicaid, it might pay that $135.50 each month for you as well.

So, we see that if you qualify for Medicaid, the first thing it does is to smooth your Medicare enrollment.

Other Medicaid-Eligible Medicare Costs: You will have additional Medicare expenses, even if you purchase extra coverage. Copayments, deductibles, insurance premiums, and prescription drugs all come into play. Depending on your level of financial need, Medicaid could pay some of those costs (partial-benefits) or all of them (full-benefits) for you.

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How Do You Qualify for Medicaid?

You qualify for Medicaid based on your finances. Medicaid needs to see difficulties with one of two things:

  1. Your income
  2. Your assets

Basically, you must be considered poor by your state’s standards.

How Poor is Poor? It Depends on Where You Live: What matters to you is that each state runs its own Medicaid program the way it sees fit. Each state sets local financial standards people need to meet in order to qualify to receive Medicaid benefits.

That’s why you might qualify for Medicaid benefits when you apply, but your friend with a similar income and comparable assets who lives in a different state isn’t able to receive Medicaid. It all depends on where you live.

Medicaid is funded by two sources: by the federal government and by each state’s government. Therefore, each state’s money to operate Medicaid within its borders is split between the federal government’s contribution and the taxes that individual state collects. Simply put, Medicaid is primarily a state-run program.

Keep in mind that income limits for Medicaid are indexed to the federal poverty level. In 2018, the limit amount for annual income in the continental U.S. was $12,140 for an individual and $16,460 for a couple.

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Full-Benefit vs Partial-Benefit: The Different Levels of Medicaid Help

As long as you’re entitled to Medicare Part A and B, and are eligible for some form of Medicaid benefit, then you’re dual-eligible. However, not all dual-eligible benefits are the same.

If you are awarded Medicaid, your benefits will fall into one of the following categories of financial assistance. Medicaid can even pay for your Medicare Part D drug plan in some circumstances. Here’s a brief overview of how each category works.

QMB Only (Qualifying Medicaid Beneficiary)

This is for people who are not eligible to receive full Medicaid benefits. Medicaid will pay the recipient’s Medicare Part A premiums (if any). It will also pay their Medicare Part B premium for them. In addition, there might be extra help with Medicare insurance deductibles and copayments.

If you’re a QMB recipient, you chose the Medicare insurance that you like. Then, Medicaid helps with your deductibles and copayments.

You will want to have good Medicare insurance, like a Medicare Advantage (Medicare Part C) plan, in place if you receive Medicaid benefits. Remember, QMB is a ‘dual-eligible’ program, not a Medicaid-only program.

Maximum monthly income for those age 65 and over to qualify for QMB in 2018 is $1,324 for an individual, and $1,666 for a couple. For 2018, the maximum asset level is $7,560 for an individual and $11,340 for a couple.

In certain situations like nursing home benefits, people with greater assets might be asked to “spend down” their assets first before Medicaid kicks in with help.

QMB Plus (with full Medicaid)

The QMB Plus category is for people with incomes lower than QMB levels. It provides full Medicaid benefits, including free or nearly-free medical services and nursing home care.

In 2018, the maximum monthly income is $1,032 for an individual and $1,392 for a couple. For 2018, the maximum asset level is $7,560 for an individual and $11,340 for a couple.

SLMB Only (Specified Low-Income Medicare Beneficiary)

If you’re an SLMB recipient, Medicaid will just pay your Medicare Part B premium.

In 2018, the maximum monthly income is $1,234 for an individual and $1,966 for a couple. For 2018, the maximum asset level is $7,560 for an individual and $11,340 for a couple.

SLMB Plus (SLMB with full Medicaid)

SLMB plus members will see Medicaid will pay your Medicare Part B premium and provide full Medicaid benefits.

In 2018, the maximum monthly income to qualify is $1,226 for an individual and $1,644 for a couple. For 2018, the maximum asset level is $7,560 for an individual and $11,340 for a couple.

QDWI (Qualified Disabled and Working Individual)

You may be eligible to purchase Medicare Part A benefits, but unable to afford it because of your low income. In this case, Medicaid will pay your Medicare Part A premium. This is more common with people under the age of 65.

In 2018, the maximum monthly income to qualify is $4,132 for an individual and $5,572 for a couple. The 2018 maximum asset level, however, is set at just $4,000 for an individual and $6,000 for a couple.

QI (Qualifying Individual)

QI is another category in which Medicaid will only pay your Medicare Part B premium.

In 2018, the maximum monthly income is $1,386 for an individual and $1,872 for a couple. For 2018 QI recipients, the maximum asset level allowed is $7,560 for an individual and $11,340 for couples.

Close to Dual Eligibility? Check With Your State’s Medicaid Office

As part of the Affordable Care Act, each state was given the opportunity to broaden its Medicaid assistance levels. Some states agreed to expand coverage but others did not. So don’t automatically rule yourself out – discuss your circumstances with your local social services provider.

The Medicare-Medicaid Coordination Office: Medicaid can be quite confusing. Complexity keeps some people from even applying for Medicaid, even though the application process is quite simple.

To help solve that problem, the federal government runs a Medicare-Medicaid Coordination Office. The office streamlines the experience of getting healthcare to those who need it. They work to develop insurance policies designed to work especially with dual-eligible citizens.

How Seniors Apply for Medicaid

If you live near a large metropolitan area, chances are good there is a local benefits assistance office near you. If not, then you can ask your state, local or county government to apply.

What if Your Doctor Only Accepts Medicare and Not Medicaid?

If you’ve been approved for Medicaid benefits, then congratulations. But doctors are not required to accept Medicaid payment. Why? It would require more paperwork for them, and Medicaid reimbursements can be less than other forms of insurance. What can you do?

  • Remember that there are presently over 70,000,000 people on Medicaid. Therefore, many doctors are indeed treating people with Medicaid coverage.
  • If you already have a doctor you like, explain to him or her that you recently received Medicaid. They might continue to see you as a patient, even if they are not accepting other new patients on Medicaid. After all, you are an established patient of theirs.
  • You might have to put a little effort into finding doctors in your area who accept Medicaid payment. Try searching the physician finder websites in your area, ask your Medicaid contact person, and call individual doctors’ offices.
  • If a doctor’s office says they don’t accept Medicaid, ask for a referral to a practice that does accept new Medicaid patients.

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Dual Special Needs Insurance

Even better, some insurance companies offer Medicare insurance packages specifically designed to work with your Medicaid dual-eligible status.

How so? If you have certain chronic health conditions (a common combination is diabetes and heart disease), you might be better served by one of the dual special needs Medicare insurance plans that have extra benefits to address those specific conditions.

Where Can You Find Insurance for Your Dual-Eligible Medicare + Medicaid Status?

We can connect you with Medicare plans specially designed for people who have dual-eligible status. It’s easy to learn more, and it’s free for you. Just give us a call and we’ll put you in contact with an independent, specially-trained agent who will answer all your questions.

Medicaid in combination with Medicare is a great health insurance package. With dual-eligible status, you get the benefit of both programs.

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