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Dual Eligibility: Using Medicare and Medicaid at the Same Time

Last updated June 18th, 2020

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Some people who receive Medicare and face significant health and financial challenges may also qualify for Medicaid. And it’s free. 

If you have both Medicare and Medicaid coverage, then your status is called dual-eligible or Medicare 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 full-benefit Medicaid coverage or only partial benefits. Keep in mind that whatever amount you receive will be in addition to your normal Medicare benefits.

This article will explain how Medicaid may 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 premiums, out-of-pocket costs, etc.  Copayments for medical services and prescriptions can 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 covers medical expenses, long-term care services, case management, and much more. Medicaid is a different program than Medicare.

Medicaid is for people whose incomes are close to the federal poverty line. Today, Medicaid provides extra help paying doctor bills, hospital bills, and prescriptions for millions of Americans aged 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: Others besides seniors can receive Medicaid benefits In all states, Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. In some states the program covers all low-income adults below a certain income level. People with a disability or certain medical conditions may 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 both Medicaid and Medicare 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 may 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 may pay it for you.

Medicaid Part B Payment Help: Everybody must pay a Medicare Part B premium of about $144.60 monthly, regardless of income. Can’t afford it? If you qualify for Medicaid, it may pay the premium for you.

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

What are the income requirements? It Depends on Where You Live: Medicaid is primarily a state-run program. Each state runs its own Medicaid program the way it sees fit. They also set local financial standards to receive Medicaid benefits.

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

Medicaid has two funding sources: the state and the federal government. Therefore, the money to operate Medicaid is split between the federal government’s contribution and the taxes a state collects.

Keep in mind that annual income limits for Medicaid are indexed to the federal poverty level. In 2020, the limit in the continental U.S. was $12,760 for an individual and $17,240 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 program 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. Besides, there may 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 aged 65 and over to qualify for QMB in 2020 is $1,061 for an individual and $1,430 for a couple. For 2020, the maximum asset level is $7,730 for an individual and $11,600 for a couple.

In certain situations like nursing home benefits, people with greater assets may 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 2020, the maximum monthly income is $1,061 for an individual and $1,430 for a couple. For 2020, the maximum asset level is $7,730 for an individual and $11,600 for a couple.

SLMB Only (Specified Low-Income Medicare Beneficiary)

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

In 2020, the maximum monthly income is $1,269 for an individual and $1,711 for a couple. For 2020, the maximum asset level is $7,730 for an individual and $11,600 for a couple.

SLMB Plus (SLMB with full Medicaid)

If you’re an SLMB Plus member, Medicaid will pay for their Medicare Part B premium and provide full Medicaid benefits.

In 2020, the maximum monthly income to qualify is $1,269 for an individual and $1,711 for a couple. For 2020, the maximum asset level is $7,730 for an individual and $11,600 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 2020, the maximum monthly income to qualify is $4,249 for an individual and $5,722 for a couple. The 2020 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 2020, the maximum monthly income is $1,426 for an individual and $1,923 for a couple. For 2020, QI recipients, the maximum asset level allowed is $7,730 for an individual and $11,600 for couples.

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

As part of the Affordable Care Act, each state was allowed 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?

Doctors are not required to accept Medicaid payment. Why? It requires more paperwork for them, and Medicaid reimbursements can be less than other forms of insurance. What can you do?

  • Remember that there are more than 70 million 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 may 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 may 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 may be better served by one of the dual special needs Medicare insurance plans that have extra benefits to address those specific conditions.

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