How Medicare and Medicaid Coordinate for Dual Eligible Beneficiaries

People often confuse Medicare and Medicaid. Since the two are only a couple of letters different and both offer health insurance, it’s easy to see why! Plus, some people are eligible to be on both programs at the same time. These people are referred to as dual-eligible beneficiaries.

Surprisingly, millions of Americans are eligible for both Medicare and Medicaid. There are many people who take advantage of these benefits, but it’s difficult to understand how the two work together to provide coverage.

Today, we’re going to review the differences between Medicare and Medicaid and learn how they coordinate coverage for people who are eligible for both.

The Difference Between Medicare and Medicaid

To understand how these programs work together, we first need to grasp the basics of each program individually. Let’s go through a quick review of each one.

What Is Medicare?

Medicare is a federal program that provides health coverage for individuals aged 65 and older, as well as some younger individuals with certain disabilities or End-Stage Renal Disease (ESRD). There are four distinct parts of Medicare: Parts A, B, C, and D.

Each part offers coverage for a different aspect of your healthcare. Part A covers hospitalizations; Part B covers outpatient services; Part D covers prescription medications. Part C is also known as Medicare Advantage. It combines the coverage offered by the other parts of Medicare.

What Is Medicaid?

Medicaid is a state and federal program that provides health coverage to people with a low income, including some low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid programs must follow federal guidelines, but they vary somewhat from state to state.

Medicaid can cover a broader spectrum of healthcare services than Medicare. It covers many of the same services as Medicare, plus some that Medicare doesn’t cover, such as long-term care. Eligibility rules for Medicaid are complex and vary from state to state, often based on income and personal circumstances.

Dual-Eligible Beneficiaries

Being a dual-eligible beneficiary can provide substantial financial and healthcare benefits. With both Medicare and Medicaid, coverage can be even more comprehensive. Medicare provides a broad range of healthcare coverage, and Medicaid can supplement this coverage by paying for costs not covered by Medicare, including Medicare premiums, deductibles, and copayments. In addition, Medicaid may cover additional services that Medicare does not cover, such as long-term care and certain home and community-based services.

In addition, some people will have access to a special kind of Medicare plan called a Special Needs Plan or SNP. There are several types of SNPs, but one is specifically designed for dual-eligible beneficiaries. This is called a D-SNP. 

Not all areas of the country have D-SNPs, and again, there are certain eligibility requirements you must meet to enroll. However, if you have one available to you, it will offer extensive benefits.

How Medicare and Medicaid Coordinate for Dual Eligible Beneficiaries

When someone is eligible for both Medicare and Medicaid, the two programs work together to provide robust health coverage. Medicare is considered the primary payer, meaning it pays first for healthcare services. Medicaid then steps in to cover the remaining costs, including premiums, deductibles, copayments, and services not covered by Medicare.

Applying for and maintaining both benefits involves engaging with federal (for Medicare) and state (for Medicaid) entities. For Medicare, beneficiaries typically are automatically enrolled when they turn 65 or have been receiving disability benefits for two years. For Medicaid, beneficiaries must apply through their state's Medicaid program. The application process often requires comprehensive information about income, assets, and medical needs.

Renewal for Medicaid coverage typically occurs annually and requires the submission of current income and asset information. Medicare does not require a renewal process, but beneficiaries should review their coverage annually during the open enrollment period to ensure they are enrolled in the plan that best meets their needs.

Don’t worry; you don’t have to do this alone! Local Medicare Specialists are here to help. Our services go beyond just consultation. We offer comprehensive support for all your Medicare and Medicaid needs. This includes helping with applications and renewals, understanding changes in coverage or eligibility requirements, and offering advice on the best plans for your specific needs.

Are you ready to unlock the full potential of your healthcare coverage? Contact Local Medicare Specialists today.