If You Have Both Medicare and Medicaid, Your Coverage May Work Differently

Some people qualify for both Medicare and Medicaid. When that happens, the two programs can work together to help cover healthcare costs and services. That can be very beneficial—but it can also be confusing.

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You may hear terms such as dual eligible, Medicare Savings Program, Extra Help, Special Needs Plan, or D-SNP. You may receive information from Medicare, Medicaid, insurance companies and state agencies, all describing different benefits and eligibility rules. It can quickly become difficult to understand what applies to you.

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At Rogue Valley Insurance Partners, Gina can help you sort through the terminology, understand your current coverage and explore Medicare plan options that may be available based on your eligibility.

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What Does “Dual Eligible” Mean?

If you qualify for both Medicare and Medicaid, you may be referred to as dual eligible. Medicare is generally your primary source of health coverage for Medicare-covered services. Medicaid may then help with certain costs or services, depending on the type of Medicaid assistance you qualify for.

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Not everyone who receives Medicaid assistance receives exactly the same benefits. Some people qualify for full Medicaid coverage. Others may qualify for a Medicare Savings Program that helps with specific Medicare expenses, such as the Part B premium or certain out-of-pocket costs.

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That distinction matters because your level of Medicaid eligibility can affect the types of Medicare plans and additional assistance available to you. This is one reason why comparing plans based only on an advertisement—or on what worked for a friend or family member—can be misleading. Your eligibility is personal to you.

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Medicaid May Help With Medicare Costs

For people who qualify, Medicaid or a Medicare Savings Program may help pay certain Medicare-related expenses.

Depending on your eligibility, assistance may include help with: Medicare Part B premiums, Certain deductibles, copayments or coinsurance, Medicare Part A premiums, if you are required to pay one, prescription drug costs, and other healthcare services or benefits that Medicare may not cover

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The amount of help you receive depends on the program for which you qualify. That's why it's important to know not only that you have Medicaid assistance, but what level of assistance you have. Gina can help you identify the information you'll need when reviewing Medicare plan options.

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What Is a Medicare Savings Program?

Medicare Savings Programs are state-administered programs designed to help eligible people with limited income and resources pay certain Medicare costs. There are several different Medicare Savings Program categories, and each provides a different level of assistance. For example, some programs may help pay your Medicare Part B premium, while others may also help with Medicare deductibles, copayments and coinsurance. Eligibility requirements can vary, and states may apply rules that differ from the basic federal guidelines. Even if you're unsure whether you qualify for assistance, it may be worthwhile to investigate. The important thing is not to assume that help is unavailable simply because you haven't applied before.

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Extra Help With Prescription Drug Costs

People who qualify for Medicaid or certain Medicare Savings Programs may also qualify automatically for a Medicare program called Extra Help.

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Extra Help is designed to reduce certain Medicare Part D prescription drug costs.

Depending on eligibility, it may help with drug plan premiums, deductibles and the amount you pay when filling covered prescriptions. For someone who takes several medications, this assistance can make a meaningful difference.

Prescription drug coverage is also one of the areas where reviewing your Medicare plan carefully becomes especially important. Different plans may cover medications differently and may use different pharmacy networks or formularies.

 

Having Extra Help does not necessarily mean that every Medicare prescription drug plan will work equally well for your particular medications. Your prescription list still matters.

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What Is a Dual Eligible Special Needs Plan?

Some people who have both Medicare and Medicaid may qualify for a type of Medicare Advantage plan called a Dual Eligible Special Needs Plan, commonly shortened to D-SNP.

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D-SNPs are designed specifically for people who meet certain Medicare and Medicaid eligibility requirements.

Like other Medicare Advantage plans, they provide Medicare Part A and Part B coverage through a private Medicare-approved insurance company. They also include Medicare prescription drug coverage. Many D-SNPs are designed to coordinate Medicare and Medicaid benefits more closely. Depending on the plan and your eligibility, additional benefits may also be available.

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However, D-SNPs are not identical. Plan availability varies by location, eligibility requirements can differ, provider networks vary and benefits can change from one plan to another. That's why the question shouldn't simply be:

“Do I qualify for a D-SNP?” A better question is: “If I qualify, which available option works best with my doctors, prescriptions, healthcare needs and Medicaid benefits?”

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Don't Assume Every Plan Offers the Same Benefits

Advertisements for Medicare plans may highlight benefits such as dental, vision, hearing, transportation, over-the-counter allowances or other services. Some plans may offer benefits like these. But availability, eligibility, limits and costs can vary significantly by plan and service area. That makes it especially important to look beyond the headline benefit.

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Before enrolling, you'll want to understand questions such as: Are my doctors and specialists in the plan's network? Are my prescriptions covered? Which pharmacies can I use? What healthcare costs might I still be responsible for? How does the plan coordinate with my Medicaid coverage? Which additional benefits am I actually eligible to receive? Those details matter far more than an advertisement.

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Questions Gina Often Hears

If I have Medicaid, do I still need Medicare?

If you qualify for both programs, Medicare and Medicaid generally work together rather than one simply replacing the other. Medicare typically covers Medicare-approved services first, while Medicaid may help with certain remaining costs or additional services depending on your eligibility.

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Does everyone with Medicare and Medicaid qualify for the same benefits?
No. Medicaid eligibility levels differ, and available Medicare plans and benefits can vary by location and individual circumstances.

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What is a D-SNP?
A Dual Eligible Special Needs Plan is a Medicare Advantage plan specifically designed for certain people who qualify for both Medicare and Medicaid.

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Can Medicaid help pay my Medicare premium?
Depending on your eligibility, Medicaid or a Medicare Savings Program may help pay your Medicare Part B premium and possibly other Medicare-related costs.

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Can I change Medicare plans if I have Medicaid?
People who have Medicaid or receive Extra Help may have additional opportunities to change certain Medicare coverage outside the standard annual enrollment periods. The specific options depend on your situation.

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Understanding Your Eligibility Can Open the Door to Better Decisions

When Medicare and Medicaid come together, there may be valuable assistance available—but understanding how the programs coordinate can be challenging. You don't need to memorize program names or figure out eligibility categories by yourself. Gina can help you review your current Medicare coverage, understand how your Medicaid status may affect your options and compare plans available in your area. Most importantly, she'll help you focus on the things that matter to you:

• Your doctors.

• Your prescriptions.

• Your healthcare needs.

• Your budget.

• And your peace of mind.

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Let's Make Sure You Understand Your Options

If you currently have both Medicare and Medicaid—or think you may qualify for additional assistance—it's worth having a conversation. Bring your Medicare information, Medicaid information and current prescription list, and let Gina help you understand what options may be available. Call Gina today to schedule a no-obligation Medicare and Medicaid coverage review. You may have more choices—and more help available—than you realize.