Can a Medicare Advantage Plan and Medicaid work together?

Depending on dual eligibility, a person may benefit from having both Medicare Advantage and Medicaid. Having dual eligibility helps ease financial burdens and opens up a more extensive network of medical service providers to access medical care.

How is a Medicare Advantage Plan different from Medicaid?

Medicare and Medicaid originate from the same “parent” institution—the Centers for Medicare and Medicaid Services. While Medicare is a government health program, Medicaid is offered by the state based on specific federal rulesMedicare Advantage, also known as Part C, is a health insurance plan offered by private companies that contract with Medicare and are approved by them. This plan combines both Medicare Parts A and B and often provides additional benefits at an extra cost. Prescription drug coverage is also usually a part of the plan’s offerings. While Medical Advantage plan enrollees will have to bear some medical expenses on their own, there is typically a ceiling set on such out-of-pocket costs.

To be eligible for a Medicare Advantage plan, a person usually needs to be over 65 years of age. People who are younger but possess specific disabilities can also qualify, along with others who suffer from End-Stage Renal Disease. If a person wants to check their eligibility to apply for Medicare, their local Social Security office can help.

Medicaid is a program offered by the federal and state government designed to help pay for medical services if their income is below a certain limit or they have specific severe disabilities. Medicaid often helps cover some services that Medicare may not cover. These include care at nursing homes; personal care; as well as community- and home-based services. States may differ in the benefits they offer, and some may also include occupational therapy, dental care, chiropractic help, optometry and so on. Most people who are eligible for Medicaid also get additional help from the government to pay for their prescription drugs or Medicare Part D.

While each state may vary in terms of Medicaid eligibility criteria, people who fall below a certain income level and are:

  1. 65 years or older
  2. below 19 years of age
  3. pregnant
  4. possess a disability
  5. a parent/adult who has a child to care for
  6. an adult who doesn’t have dependent children (state rules vary)
  7. an immigrant who fulfills specific qualifications.

Applying to receive Medicaid can take some time. Documentation of past and current financial obligations and often a medical screening is required to ensure that each individual truly qualifies for Medicaid.

When calculating income levels, a person’s assets are also generally taken into account Medicaid eligibility. In some situations, people who are determined over the income threshold, and have a higher income than what is required to qualify for Medicaid can still apply if their medical expenses are considerably high. Eligibility for Medicaid not only is based on income but also medical need.
As rules can keep changing, a person who applied for Medicaid in the past and was denied can try apply again if their situation changes. It is best to contact the local or State Medicaid office who can offer more information regarding eligibility.

What is Dual Eligibility?

Dual eligibility is a situation where a person qualifies for both Medicare as well as Medicaid and is beneficial for people with a low-income to help provide affordable healthcare needs a minimum cost. Under this status, people can qualify to be fully dual eligible or partially dual-eligible.

Individuals who have certain disabilities can also qualify for dual eligibility. These include people with several chronic diseases, cognitive impairment issues, mental illnesses, and physical disabilities. The extra medical and social support that dual eligibility offers can go a long way in providing for a variety of healthcare needs.

What is the difference between Full and Partial Dual Eligibility?

Every state defines their own income and asset criteria for a person to apply for full or partial dual eligibility. People who come under the “full dual eligible” category can typically avail of all the Medicaid services offered by their state, plus financial help with Medicare cost-sharing. In contrast, people who come under the partial dual eligible category generally get help to pay their Medicare premiums but don’t usually get other Medicaid services. Certain partial dual eligible plans help with Medicare cost-sharing too. However, the percentage of financial aid offered to an enrollee with regard to cost-sharing can vary from state to state.

How can you enroll in Medicare Advantage while on Medicaid?

Medicare Advantage has several plans suited for different needs. One of these is a Dual Eligible Special Needs Plan (D-SNP) which is tailored for those who qualify for both Medicare as well as Medicaid. While this plan offers the same health services as a Medicare Advantage plan, enrollees need to check if the doctor they are visiting contracts with Medicare and accepts Medicaid.

It is important that a person availing of the D-SNP lives within the service network defined by the plan and already has Medicare Parts A and B, along with full Medicaid benefits. A letter from the State Medicaid office may also be needed at the time of application.
There are several benefits of a D-SNP. A person who is on this plan can avail of medical support in the form of dental, eye and hearing services; financial aid for dental restorative work; extra help to buy eyewear and credit to purchase hearing aids. In addition, they can get help to access a pharmacy, a ride to a healthcare facility, and assistance to buy several health products.

Who pays for these Plans?

Typically, taxpayers contribute towards Medicare during their work life and, therefore, when they become eligible for Medicare Part A, they can avail of it without paying a premium. In case they haven’t worked for the required number of years, they may need to pay a premium when they apply for Part A. In addition to this, Medicare enrollees will have to pay premiums for Medicare Part B.

If a person has dual eligibility, Medicare will typically pay for services such as hospital care, doctor services, and post-acute rehabilitation. Medicaid may take care of most expenses with regards to Medicare Part A premiums (if they are applicable) and Part B premiums. They may also pay for any deductibles and copayments that exist. Also, Medicaid may take care of individual medical costs not covered by Medicare, such as personal care and nursing home care. With regards to Part D, all recipients of full Medicaid typically get “Extra Help” to cover the costs of prescription drugs.

Every state has different Medicaid plans with regards to the way they offer services, share costs, and list their eligibility qualifications. Medicare Advantage plans also vary from company to company in the healthcare benefits they provide.

If you are shopping for a new Medicare Advantage Plan, Koi Healthcare can help. Contact us today!

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