It is not unusual to be confused by the terms Medicare and Medicaid. Both programs are funded by the government and help people pay for their healthcare. But they are very different from each other, and each have their own rules for eligibility. An individual may qualify for one program or the other, and in some cases, may qualify for both. This is known as dual eligibility. Here’s what you need to know about each program and how to determine if you qualify.
Who Qualifies for Medicare
Medicare is a federal program for people who are age 65 or older and also covers some younger people who have a qualifying disability. Anyone who meets the criteria can enroll regardless of income. To qualify:
- You must be at least 65 years old and be a naturalized American citizen or permanent legal resident tor at least 5 years.
- If you are younger than 65 you can qualify if you have been receiving Social Security disability benefits for at least two years or have end stage renal disease or ALS (Lou Gehrig’s disease).
Medicare isn’t free. There are out of pocket costs such as premiums, deductibles, and copays that many seniors with limited incomes may struggle to pay. This is where Medicaid can help if you qualify.
Who Qualifies for Medicaid
Medicaid is a state run program that helps people of all ages who qualify based on limited income and assets. Each state operates its own Medicaid program and guidelines for eligibility will vary by state. The federal government mandates a common set of covered benefits for all states, but some states choose to cover additional benefits such as dental, vision, and hearing.
You can check with your state’s Medicaid office to see if you qualify. You must be a resident of the state in which you are applying. It is recommended that you apply even if you exceed the limits set, because some income and assets may not count. If you are low income but do not qualify for full Medicaid benefits, you might qualify for partial Medicaid benefits and get help from Medicare Savings Programs. Partial benefit dual eligibles do not receive the full range of benefits covered by full Medicaid. When you apply your state will help you determine which programs you qualify for.
Dual Eligibility
If you are enrolled in Medicare Part A and B and are also eligible for full Medicaid benefits or get help through a Medicare Savings program, you are considered dually eligible. For those who qualify for full Medicaid, this means that for any covered healthcare services you receive, you will have little to no out of pocket costs. Those with partial Medicaid eligibility will have more out of pocket costs. Medicare will pay first, and any costs not covered by Medicare will be covered by Medicaid according to your benefit level.
Because it can be difficult for beneficiaries to coordinate their care between the two programs, many people who are dual eligible choose to consolidate their Medicare and Medicaid coverage under one plan, known as a Dual Eligible Special Needs Plan (D-SNP). These are specially designed Medicare Advantage plans that include prescription drug coverage. D-SNP’s are offered by private insurers and are not available in all areas. You can use Medicare’s plan finder tool to see if there a D-SNP plan available in your zip code.
Special Enrollment Periods
If you are already enrolled in Medicare and become eligible for Medicaid, you will qualify for a Medicare Special Enrollment Period that allows you to change your coverage to a D-SNP if one is available in your area. Your new coverage will be effective the first of the following month.
Help is Available
Understanding Medicare and Medicaid and determining what you are eligible for might feel overwhelming, but help is available. Your state’s Medicaid office will help you determine which programs you are eligible for and can help you apply. A licensed Medicare agent or broker in your area can help you determine your Medicare eligibility. They will know if there is a D-SNP available in your area. If there is a plan available, they can help you decide if it is right for you. They will help you review all your coverage options and assist with enrolling you in the plan of your choice. Silver&Smart’s Medicare Insurance Agent Directory can help connect you with a licensed Medicare Agent in your state.