Yahoo Finance What You Need to Know About Getting Both Medicare and Medicaid
The nation's 55.5 million Medicare beneficiaries receive comprehensive health care coverage, but their benefits come at a price. Medicare Part A, which pays for hospitalizations and inpatient care, has a $1,288 deductible in 2016 plus co-insurance costs for stays exceeding 60 days. Those who want outpatient care, covered by Part B, have additional deductible and coinsurance costs, plus they typically pay a $104.90 premium each month.
"Some folks can't cover that premium," says Sabra Matovsky, executive vice president of Integrated Health Partners in San Diego. Fortunately, help is available for some people. Those with limited income and assets may be eligible for Medicaid to pay the monthly premium and other out-of-pocket costs associated with Medicare. Here are five things you should know about getting dual coverage.
[See: 10 Things You Need to Know About Medicare.]
Your Medicaid and Medicare eligibility is determined separately. The first thing to understand is that Medicaid and Medicare eligibility and enrollment are handled separately. "Everyone who is eligible for retirement [Social Security benefits] is entitled to Medicare," says Ginalisa Monterroso, CEO of Medicaid Advisory Group. Those who are disabled may also be eligible for Medicare.
While Medicare is a federal program with the same eligibility standards across the country, Medicaid is state-administered. That means each state may have slightly different requirements for who is entitled to benefits, although all states must meet a federal mandate to cover certain groups of people, such as those who have limited assets and an income that's less than 133 percent of the federal poverty level. What's more, while Medicare beneficiaries only have to apply for benefits once, most Medicaid programs require recipients to submit documentation on a regular basis to remain eligible.
There are several levels of Medicaid coverage. Not everyone who is eligible for Medicaid will get the same level of coverage. There are four programs for dual- eligible beneficiaries who receive both Medicaid and Medicare. Depending on your circumstances, you could fall into one of the following categories:
-- Qualified Medicare beneficiary. Offering the highest level of coverage, these beneficiaries may pay for Part A and Part B premiums, deductibles, co-insurance and co-payments.
-- Specified low-income Medicare beneficiary. People in this category receive Medicaid coverage for their Part B premiums.
-- Qualifying individual. This program also helps pay for Part B premiums.
-- Qualified disabled working individual. Limited to those who are disabled but still working, this Medicaid program helps pay for Part A premiums.
[Quiz: Test Your Medicare Knowledge.]
"Ideally, becoming dual eligible should enhance access to health care," says Colin LeClair, senior vice president of product development for ConcertoHealth, which specializes in assisting dual enrollees. It should reduce or eliminate cost-sharing, although some people may only receive partial coverage.
Managed care plans come with pros and cons. When it comes to receiving benefits, dual enrollees may have the option of receiving benefits straight from the government or through a managed care plan. Managed care plans are often structured as HMOs or PPOs, although LeClair says some companies are looking into newer models of care such as Accountable Care Organizations and Patient Centered Medical Homes.
Regardless of their structure, these plans often come with supplemental services that may include dental, vision or even transportation services. Medicare Advantage plans that offer supplemental services may have higher premiums, but Medicaid beneficiaries don't pay extra for a managed care plan. That doesn't mean there aren't drawbacks. "Typically, a beneficiary has to make a trade," LeClair says. "They may have access to a narrower list of providers."
Limited provider access is one reason Monterroso says people should think carefully before opting for a managed care plan. "There is a gatekeeper that can say yay or nay [to services or providers]," she says. However, by receiving benefits directly from the government, beneficiaries may be able to go to any physician or facility that accepts Medicare and Medicaid patients.
Some organizations specialize in helping dual enrollees. It's not always easy for dual enrollees to understand their benefits. "It's a full-time job to figure out what you're entitled to," Matovsky says.
One option to simplify the process is to select a health care plan that combines both Medicare and Medicaid benefits under one policy. Another may be to work with a health center or organization that offers case management services to dual enrollees. "Coordinating benefits on your own and submitting paperwork can be overwhelming," LeClair says. Using a case management service may not only eliminate some of this burden, but also help people make the most of their benefits.
Even if you're not eligible for Medicaid now, you could be later. Those who aren't immediately eligible for dual enrollment should know it's not unusual for seniors to eventually reach the point where they are able to receive Medicaid. "Once people spend down their assets and are old enough, it's not like they are going to come into money," Matovsky says.
[See: 10 Medical Services Medicare Doesn't Cover.]
Seniors and their relatives may want to contact their state's social services department in advance to learn more about Medicaid eligibility requirements. Then, when and if a person reaches that income and asset level, an application can be submitted to begin benefits as quickly as possible.
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