Dual Eligibles:Your Options In Medicare And Medicaid

Food For Thought: Before we get into the details of dual eligibles, it is important to get a clear understanding on Medicaid and Medicare and the differences between the two. I have covered different types of health insurance options in detail in this article.


Difference Between Medicare and Medicaid

I would like to highlight the difference between Medicaid and Medicare based on eligibility, which is responsible for running the program and details of coverage provided by each of the programs.

Medicare: The basic motive of creating Medicare was to ensure that medical and health related expenses are affordable for the senior citizens of the society. An important point to consider regarding Medicare that it is not a need based program but you’re entitled to it through the government. You have paid for it through social security taxes.

Eligibility: Anyone who is 65 years or older is covered under Medicare benefits. A certain group is covered who is on social security disability. Individuals suffering from diseases like kidney may also be covered.

Program Administrators: Medicare is run by the federal government and the rules are same across all states. Detail information on Medicare can be obtained at your local social security office.

Coverage: You get two types of coverage under Medicare which are classified as Part A, Part B and Part C. Part A provides cover for hospital insurance and Part B provides cover for supplementary medical insurance. You would automatically qualify for Part A if you are above 65 or suffering from disability. As mentioned above you will mostly not be paying any kind of monthly premium against Medicare facilities if you have paid your social security taxed during your working tenure. However, if you’re not entitled to Part A you can purchase individual coverage. Under Part A coverage is provided for basic hospital stays, post treatment nursing facility and in some cases home health care is also provided.

You have to pay monthly premiums for Part B coverage. Part B provides basic coverage for doctor visits and laboratory costs. Outpatient services may also be covered. If your treatment calls for a subscription to medical drug plan then you have to enroll into Medical Prescription Drug Plan.

The third category is the Part C plans. Popularly known as Medicare Advantage Plans. These plans are sold by private companies and have the approval of Medicare. Do not consider these as supplemental insurance. They provide cover for both part A and B and must follow the guidelines set by Medicare on cost sharing and benefits provided.

Medicaid: Medicaid is more of a cost sharing additional alternative for people who are already on Medicare.

Eligibility: This program is run for people who have low income and for people who have financial constraint.  Individuals above 65 years of age and already on Medicare are also eligible for Medicaid.

Program Administrators: Medicaid is jointly run by federal government and state health department. Medicaid provides cover for various pre and post hospitalization expenses.

Coverage: is most helpful in paying your out of pocket expenses. Cost sharing can be implied for part A and B premium, coinsurance and co-payment expenses. Condition is that the payment received through Medicare should not exceed the amount provided through state Medicaid programs and the state reserves the right of financial help through Medicaid under certain terms and conditions.


Dual Eligibles – Who Are They?

Now, you know the basic difference between Medicare and Medicaid. This was important to explain before we discuss dual eligibles. So who is classified for dual eligibility under Medicare and Medicaid programs?.

Definition Of Dual Eligibles: People who eligible for Medicare part A and/or B and at the same time are also eligible for some type of benefits under state run Medicaid programs are called as “Dual Eligibles”.

Currently there are approx. 9 million people who are dual eligibles. So if you become eligible for dual eligibility, you would qualify for Medicare Savings Programs (MSP). For dual eligibility status, following benefits are included:

  • Qualified Medicare Beneficiaries (QMB)
  • Specific Low Income Medicare Beneficiaries (SLIB)
  • Qualifying Individuals (QI)
  • Qualified Disabled Working Individuals (QDWI)

For details under the respective qualification groups you can contact your local social security office.


Common Gateway To Dual Eligible Benefits

  • Nursing Home Care
  • People on community based long term care

Some other characteristics of dual eligibles are people who belong to the following group:

Low Income Group:  If you are entitled to SSI cash assistance. If your income is up to 100% of the state poverty levels (Applicable in 22 states). People with disabilities (Applicable for people between 18 and 64 years of age). Disability rules vary by state.

Medically Needy Individuals With Financial Problems: If you qualify for HCBS waivers.

Institutional Level Care: Considerations under special income rule. People who are under 300% of the SSI benefits (Currently in 40 states).

Individuals who are come under the dual eligibles group generally have Medicare taking care of their primary health care needs and Medicaid fills in the gap if any for additional medical expenses. Dual eligibles are often referred to as the people who are poorest and sickest either covered by Medicare or Medicaid.


Special Needs Plan For Dual Eligibles (D-SNP)

Special needs plans are a part of Medicare advantage. It is available for people who are dual eligibles. You would qualify for these plans if you have certain chronic health conditions and currently covered by Medicaid. These plans are accessible through private insurers only.

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