When you’re exploring your Medicare and Medicaid options, you may come across the term “dual eligibility plans.” But what are these plans all about? More importantly, are they right for you? We’re here today to help you find out.
Medicare vs. Medicaid
Before you begin to navigate the world of dual eligibility, it’s important to understand the difference between Medicare and Medicaid. Both programs are vital parts of the US healthcare system, providing crucial assistance to millions of Americans. But they are designed to serve two distinct populations and have different eligibility requirements and funding sources.
What is Medicare?
Medicare is a federally run program and primarily provides benefits for Americans aged 65 and older. It also covers some younger people with disabilities. Original Medicare includes Parts A and B. Let’s examine all four of the parts that make up Medicare:
- Medicare Part A (hospital insurance) covers inpatient hospital care, skilled nursing facility care, hospice care and home health care.
- Medicare Part B (medical insurance) helps pay for doctor visits, outpatient care, durable medical equipment, home health care and some preventive services.
- Medicare Part C (Medicare Advantage) are “bundled” plans offered by private companies that provide the same benefits as Parts A and B, as well additional benefits that may include things like dental care, vision care and other services.
- Medicare Part D (prescription drug coverage) helps cover the cost of prescription drugs.
What is Medicaid?
Medicaid is a joint state and federal program that provides health coverage to low-income individuals and families, including children, pregnant women, parents, seniors and some people with disabilities. Each state runs its own Medicaid program and can decide what services to offer. But, since Medicaid is funded by both state and the federal government, some services are considered mandatory. Those typically include:
- Inpatient hospital stays
- Doctor visits and outpatient services
- Preventive care
- Nursing facility services
- Laboratory services and X-rays
- Family planning services
- Skilled nursing facilities
- Home health care
Some states offer additional benefits like dental and vision care.
Eligibility Criteria for Medicare
The primary requirement for Medicare is age. It’s designed to serve as sort of a healthcare safety net when you’re older. But you may qualify earlier if you have certain disabilities.
Age and Disability Requirements
Most American become eligible for Medicare when they turn 65. But people with End Stage Renal Disease (ESRD) or ALS (also known as Lou Gehrig's disease) may be able to qualify for Medicare before age 65. You may also qualify if you have been receiving Social Security Disability Insurance (SSDI) or Railroad Retirement Board (RRB) disability benefits for at least 24 months.
Work History
Your work history and tax contributions impact your eligibility for premium-free Medicare Part A, or hospital coverage. You need to have paid into the Social Security system by working for a total of 40 quarters (10 years), which will give you 40 work credits. If you haven't earned enough credits, you can still enroll in Part A and pay a monthly premium. Your spouse’s work history can also help. If they have enough work credits, you may be eligible for premium-free Part A through their work record. The other parts of Medicare are available to most individuals aged 65 and older without restriction, though premiums may apply. Find out how to get started and apply for Medicare.
Eligibility Criteria for Medicaid
In order to qualify for Medicaid, you must reside in the state where you are enrolling and meet the state’s requirements for income, family size, disability status and other factors. Requirements for eligibility vary by state so it’s important to check with your own state Medicaid agency for the most relevant information.
How Medicare works with Medicaid
Medicare and Medicaid can work together to give you access to more comprehensive coverage. When members need health care services, Medicare is considered the “primary payer” since it will be billed first. Medicaid is the “secondary payer” and helps to cover leftover out-of-pocket costs like copays and premiums. It may also help pay for services that Medicare doesn’t fully cover, including long-term care and personal care services.
Benefits of Dual Enrollment
Dual eligibility is when someone qualifies for both Medicare and Medicaid at the same time. This happens when a person meets the criteria for both programs. A Dual Eligible Special Needs Plan, more commonly known as D-SNP, is one type of Special Needs Plan designed for this specific population.
Coverage and Cost Advantages
D-SNPs typically offer benefits that go beyond traditional Medicare coverage, including things like dental coverage, transportation assistance, over-the-counter (OTC) allowance and more. D-SNPs also offer care coordination services that help manage complex health conditions and provide access to necessary treatments and community resources. Many D-SNPs come with $0 premiums, copays and deductibles, which can help save you money.
Wellcare offers D-SNPs that work with your Medicaid coverage to help lower your out-of-pocket costs and give you additional benefits. Contact us to see if there’s a Wellcare Medicare Advantage D-SNP plan available in your market.
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