Medicare and Medicaid can benefit those with financial difficulties. If you don’t know the difference between Medicare vs. Medicaid health plans, you’re not alone. The two names are so close to one another, yet they’re different health plans. In 1965, President Lyndon B. Johnson signed the Medicare and Medicaid Act into law.
Below, we’ll go over the difference between Medicare and Medicaid. Also, we discuss dual-eligibility and plan options.
Guide to Medicaid and Medicare Dual-Eligibility
Many people confuse these two plans. But, Medicare is for those over 65 or with long-term disability. Then, Medicaid is for those with low income and few resources.
Beneficiaries eligible for both are Dual Eligible. Medicare and Medicaid recipients that need Programs of All-Inclusive Care for the Elderly (PACE) may qualify.
Criteria for Medicaid can differ between states. To qualify, you need to be under a specific income limit. Your assets must not exceed more than $2,000 for an individual and $3,000 for couples.
Medicare is a federal program similar to the typical type of insurance that you may receive from your employer.
Premiums are due monthly, and there are deductibles and coinsurances.
You qualify for Medicare if:
- US citizens 65 years and older
- Anyone collecting disability for 24 months regardless of age
- Those with end-stage renal failure or Lou Gehrig’s disease
Medicaid is free to individuals in need, mostly children. Medicaid is a joint program between federal and state governments. Unlike Medicare, the rules vary between states.
Medicaid covers the following:
- Doctor visits
- Inpatient and outpatient hospital care
- Lab tests
- Home health care
- Hospice care
- Medical equipment and supplies
- Non-emergency medical transportation services
- Dental care (up to age 21)
- Long Term Care
Just because Medicaid is free doesn’t mean it’s for everyone. Criteria vary between states.
In general, pregnant women that meet guidelines receive same-day Medicaid. Women without insurance and suffering from breast or cervical cancer are eligible for Medicaid.
Approval time for Medicaid can take up to 60 days. Benefits are for US citizens; but, children of illegal immigrants can qualify.
If you get Social Security Supplemental benefits, you’ll qualify for Medicaid. Also, Medicaid has benefits Medicare doesn’t; this includes vision, dental, and long-term custodial care.
Is there Dual Eligibility for Both Medicare & Medicaid
You can collect both; this is “dual eligibility.” Medicare will pay out before Medicaid. Your Medicaid will act like Medigap.
To Qualify for Dual-Eligibility:
- Meet the income requirements in your state for Medicaid
- Eligible for Medicare due to aging in or disability
Medicaid and Medicare Enrollment Help
Beneficiaries can enroll in Medicaid through the state program office. If you think you’re eligible, contact your state health department to apply.
But, you apply for Medicare through Social Security. You can apply online at the Social Security Administration website.
What is the difference between Medicare & Medicaid?
Although the two programs share the same prefix and offer health coverage, they’re different.
Nearly every American will one day qualify for Medicare, but Medicaid is only for those with a low-income.
With Medicare, think “care” for those 65+ or those with disabilities. Then, Medicaid is “aid” to those with a low income.
Medicaid is free. Medicare is not free.
Low-Income Subsidy and Medicare
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) mandated the Part D Program along with Low-Income Subsidy (LIS).
Well, the act gave options for drug coverage. Then, Low-income subsidy helps cover the costs.
Extra help is for those with low income and few resources. You may apply for the subsidy with the State Medicaid agency or Social Security.
After the application, following acceptance, you’ll get help with Part D costs. Also, low-income subsidy enrollees are exempt from the Medicare “donut hole.”
What are the Income Limits for Extra Help with Medicare Part D
If you’re single and have an annual income of $18,735 or less, you’re eligible for the Part D Low-Income Subsidy.
The Extra Help program helps you cover your costs through Part D. It can cover deductibles, copays, and premiums.
If you get help through this program, you’ll pay no more than $8.95 for brand-name drugs. Also, you can plan on spending no more than $3.60 for generics in 2020.
Applying for the Low-Income Subsidy
Social Security or the State Medicaid office will determine eligibility. Applicants must calculate any assets of theirs.
Assets may include any income property, mutual funds and IRAs, cash/bank accounts, and stocks/bonds. Insurance policies, vehicles, and primary residence are not assets.
The easiest way to determine if you are eligible is by applying.
Consumers may find benefits in applying for low-income subsidy and the Medicare Savings Programs. States must use Federal rules for determining the subsidy application decision.
Beneficiaries with a Medicare Savings Program, Medicaid, or Supplemental Security Income automatically qualify for the low-income subsidy.
Notices and Appeals
What happens if you get a denial for your Extra Help application? You can choose several different routes to tackle the issue.
Before the final decision sets in stone, you’ll receive a Pre-Decisional Notice. The notice explains why you’re not eligible.
You’ll have ten days from the date on the notice you get to make corrections. Once Social Security makes its decision, you’ll get a Notice of Award.
The notice will tell you which level of coverage you’ll receive, or you may get a Notice of Denial. A denial means you don’t meet the necessary qualifications.
If you disagree with the denial, you can request an appeal hearing within 60 days of rejection. Sometimes people don’t want actual interviews. You can ask for a case review, and you may send in any other information you feel is pertinent.
Depending on how your hearing goes, you’ll get a notice for approval or denial. If you still disagree, you can appeal to the Federal District Court.
Is there a Special Enrollment Period for Medicare Dual Eligible
Those with Medicaid and Medicare qualify for a Special Enrollment Period (SEP); you can disenroll, join, or switch plans.
The Special Enrollment Period begins the month a person is eligible for assistance. The new plan becomes valid on the first day of the month after enrolling.
If you need Extra Help, apply for the low-income subsidy.
Are there Medicare and Medicaid Special Needs Plans
A Medicare Advantage Special Needs Plan could help cover costs. The plan may cover routine dental, vision, and hearing.
Some plans even include a gym membership such as silver sneakers.
Is there a Medicaid Guaranteed Issue for Loss of Coverage
In some states, with specific companies, losing Medicaid means gaining eligibility for Guaranteed Issue Rights. Rights allow you to select Medigap without underwriting.
You must have Part B to enroll in a Medigap policy. Not all plans are available with every company.
The state you live in impacts eligibility. Contact one of our agents to find the best plan for your needs.
What is the PACE Program
The PACE program provides social and medical services to elderly patients actively living in the community. PACE is a program under Medicare that many states can choose whether or not to participate.
States can choose to offer PACE services to their Medicaid participants as an optional choice that will fall under Medicaid’s services. There are currently more than 51,000 PACE participants among 31 states.
Most times, these elderly patients qualify for both Medicare AND Medicaid. PACE programs are non-profit organizations whose goal is to provide patients with quality health care. The program is designed to offer many services to eligible participants who may require much daily care but may not live in a typical nursing home situation.
How does the PACE Program Work
PACE centers have a set of “PACE-specific” doctors and specialists. This team of experts can provide health care for patients in PACE centers, patients’ homes, and other sources within the community.
PACE centers will review their patients’ specific needs and create care plans around those needs. The team members are essential as they’re the ones ensuring patients meet medical and social needs.
These centers can then provide all services necessary.
Typically, PACE care teams consist of a:
- Primary care doctor
- Physical therapist
- Social worker
Who Qualifies For Programs of All-Inclusive Care for the Elderly
To qualify for the PACE program, you be at least 55 years old, live within the service of PACE, have either Medicaid or Medicare, and must require home care. Seniors must also be able to live safely within their community.
PACE participants are very similar to nursing home residents. A single individual cannot earn more than $14,500 per year, and a married couple cannot earn more than $17,000 to qualify for PACE services.
The PACE program is 100% voluntary. If enrollees met all requirements and choose to move forward with the program, they’ll sign an agreement.
Enrollees can choose to stay enrolled in the program for as long as they need, even if their current health conditions drastically change.
Services Programs of All-Inclusive Care for the Elderly Covers
The PACE program covers a variety of health services for patients.
- Preventative care
- Meal preparation
- Emergency care services
- Home health care
- Transportation services to adult day health centers
- Social services such as respite care
- Training for family and caregivers
In addition to the services offered above, PACE can provide a wide variety of other much-needed services.
Many times, these services are daily in an adult day health center, and the patient can get extra care in their home, depending on just what their daily needs are.
Also, PACE enrollees are eligible to get any comprehensive care. If a senior requires end-of-life care, they can obtain pharmaceutical, medical, and social responsibility.
If a patient chooses to utilize their hospice benefits, they must disengage from the PACE program.
Apply for Programs of All-Inclusive Care for the Elderly
The best way to determine eligibility in the PACE program is to contact the closest organization. Also, Patients can discover if there are any local PACE centers by calling into the state Medicaid office.
Depending on what your income looks like, there may be severe fluctuation with PACE service cost amounts. If patients have coverage under Medicaid, they will not be responsible for monthly premium costs of PACE benefits.
If a patient has Medicare but doesn’t qualify for Medicaid, they may have monthly premiums for Part D and a monthly premium that covers long-term care under the PACE program.
Medicare and Medicaid FAQ’s
Get Help Finding a Medicare and Medicaid Policy
Medicaid and Medicare are not that similar. Medicaid is available to individuals and families living below the poverty level. But, Medicare is for people 65 and older, as well as those on disability.
Once you have clarity on the facts regarding Medicare vs. Medicaid, you can make the right decisions. If you have questions about your Medicare options, contact us today.
Our senior agents can inform you of all your options. Call our team of experts, and we can help you review your best options.