How Medicare and Medicaid Work Together

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There are many factors that play into how Medicare and Medicaid work together. In some cases, certain individuals may even be eligible to receive healthcare coverage from both government-managed programs. However, before we get into the more complex details, we must first discuss the main differences between Medicare and Medicaid.

What is the difference between Medicare and Medicaid?

Given the many similarities between these two government-managed health insurance programs, it is relatively common for people to confuse the two. However, it is important to remember that Medicare and Medicaid are two separate programs, and the terms are not interchangeable. Each program targets different healthcare needs and specific groups of people.

What is Medicare?

Medicare is a health insurance program that is managed and regulated by the U.S. federal government. It is designed to be a main health insurance program for individuals aged 65 or older or those who have been diagnosed with certain disabilities, including End Stage Renal Disease.

What does Medicare cover?

Medicare coverage consists of four main parts:

Medicare Part A provides hospital insurance for services like inpatient hospital care, inpatient care art a skilled nursing facility, hospice care, and some other home health services. It is one half of what is known as “Original Medicare.”

Medicare Part B provides medical insurance for services like physician appointments, outpatient care, durable medical equipment, home health services, and preventative care like vaccines and screenings. It is the other half of Original Medicare.

Medicare Part C, also known as “Medicare Advantage,” consists of separate insurance policies offered by private insurance companies. Medicare Advantage plans can provide additional coverage that Original Medicare does not cover, including hearing, vision, and dental needs.

Medicare Part D is responsible for the coverage of prescription medications. Many Medicare Advantage plans offer Part D as part of coverage, but Part D is also available as a standalone option as well.

What is Medicaid?

Like Medicare, Medicaid is a government-managed health insurance program. However, Medicaid is managed by both the U.S. federal governments and individual state governments. Medicaid is designed to assist low-income and limited-resource individuals and families in paying for certain healthcare services and treatments. Not all doctors or specialists always accept Medicaid, so it is a good idea to check with your provider to determine whether you are covered.

There is no specific enrollment period for Medicaid, but many states require that you update your enrollment information each year to ensure you still qualify.

While the federal government sets the broader rules, regulations, and policies for Medicaid coverage, each state is responsible for following those guidelines within their own circumstances. When it comes to Medicaid, each state is responsible for:

• Establishing its own eligibility standards
• Determining the type, amount, duration, and scope of covered services and treatments
• Setting service payment rates
• Administering its own individual program

What does Medicaid cover?

Medicaid coverage can vary between states, but generally, Medicaid provides some healthcare coverage for limited-income individuals over the age of 65, children under 19 years old, pregnant women, individuals with qualifying disabilities, parents or guardians caring for a child, or adults without dependent children (in most states).

Typically, successful enrollment in Medicaid can give you access to the following healthcare benefits, many of which are not covered, or only partially covered, by Medicare:

• Doctor’s visits
• Hospital stays
• Long-term healthcare services and support
• Preventive care (vaccines, mammograms, colonoscopies, etc.)
• Nursing home care
• Transportation to and from appointments
• Prenatal and maternity care
• Mental health services
• Necessary medications
• Vision and dental care for children
• Medicare Part A deductibles and copays
• Medicare Part B premiums, deductibles, and copays
• Medicare Part D premiums, deductibles, and copays (a.k.a. the Extra Help program)

Can I have both Medicare and Medicaid?

It may come as a surprise to many, but the answer is yes. It is indeed possible to be covered by both Medicare and Medicaid. But how do Medicaid and Medicare work together?

What does it mean to be dual eligible?

Many individuals have what is know as dual eligibility, meaning they are qualified to receive both Medicaid and Medicare coverage, including Medicare Advantage plans.

If you qualify for both Medicare and Medicaid and are enrolled in both programs, Medicare will generally cover health services received first, and Medicaid funds are used as a secondary or “last resort” means of coverage.

The term “dual eligible” also applies to beneficiaries enrolled in Original Medicare who also receive full Medicaid benefits and/or assistance through with Medicare premiums and cost sharing via a Medicare Savings Program (MSP). The four Medicare Savings Programs are as follows:

The Qualified Medicare Beneficiary (QMB) Program

The QMB program is an MSP that helps pay for Original Medicare premiums as well as deductibles, coinsurance, and copays. If you qualify for this program, you will also qualify for Extra Help, a prescription drug coverage program designed to help you with out-of-pocket costs associated with medication.

The Specified Low-Income Medicare Beneficiary (SLMB) Program

The SLMB program is an MSP that only helps pay for Medicare Part B premiums, not Part A or any other cost sharing. If your income is too high to qualify for the QMB program, you may qualify for the SLMB program. Like QMB, individuals who qualify for SLMB will also qualify for Extra Help.

The Qualifying Individual (QI) Program

The QI program is similar to the SLMB program in that it provides assistance in paying for Part B premiums only and no other cost sharing. If your income is too high to qualify for QMB or SLMB, you may qualify for QI. Because funding through this program is limited, you must reapply for QI benefits every year. QI benefits are offered on a first come, first served basis, with priority given to those who already qualified for QI the previous year.

The Qualified Disabled and Working Individuals (QDWI) Program

The QDWI program only helps pay for Medicare Part A premiums. It is designed for those with disabilities under the age of 65 who are still working and have lost their coverage as a result. In order to qualify for the QDWI program, you cannot be receiving Medicaid benefits in your state, but you must meet your state’s income and resource limits.

Are you wondering about your eligibility status? Are you dual eligible and interested in the possibility of expanding your Medicare coverage through Medicare Advantage? If so, feel free to utilize our live chat feature or contact us by phone today at (800) 950-0608 today to speak to a live agent about your potential options.