Healthcare costs in our country are out of control, putting millions of Americans at risk. Fortunately, we have MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. as a social safety net system.
Without Medicaid, millions of people would be unable to afford their Medicare benefits. They would not be able to pay their monthly premiumsA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. , the out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. to see a doctor or the cost of their prescriptions.
In this article, we’ll discuss how you or a loved one can qualify for both Medicare and Medicaid. We’ll go over all of the different programs available and which ones might be best for you.
- Medicare is health insurance, from the federal government, for people ages 65 and up.
- People with certain disabilities also qualify for Medicare.
- Medicare covers about 80% of a beneficiaries major health care costs. The remaining 20% is the beneficiary’s responsibility.
- Medicaid is health insurance for low-income individuals and families.
- Medicaid covers most of a beneficiary’s healthcare costs, including routine dental, vision, and hearing care, and prescription drugs.
- When Medicare beneficiaries meet the Medicaid eligibility requirements, they are dually eligible for both programs.
- When dually eligible, Medicaid pays many out-of-pocket costs for Medicare beneficiaries, including premiums, deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., and copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service..
What are Medicare and Medicaid?
Medicare is a federal program for adults aged 65 or older and those with certain disabilities. Many people are surprised to learn that Medicare is not end-to-end healthcare.
In fact, from the beginning, Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. was designed to cover only about 80 percent of a beneficiary’s major medical expenses. All other costs, typically in the form of deductibles, coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. , and copayments, are the beneficiary’s responsibility.
When a beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. cannot afford the cost of their Medicare coverage, there’s Medicaid. Although Medicaid provides health insurance to low-income families and individuals, it also assists people with Medicare by covering many out-of-pocket costs.
Can I Have Both Medicare and Medicaid at the Same Time?
Yes. If you qualify for both Medicare and Medicaid, you can have them both simultaneously. When you have both, Medicare is the primary payor and Medicaid is secondary.
Around 20 percent of Medicare beneficiaries are eligible for Medicaid. They are called dual-eligibleDual-eligible beneficiaries are those who receive both Medicare and Medicaid benefits. It includes beneficiaries enrolled in Medicare Part A and/or Part B while receiving full Medicaid and/or financial assistance through a Medicare Savings Program..... You would need to apply for each one separately to determine if you can qualify for both.
Dual-eligibles are categorized based on whether they receive full or partial Medicaid benefits. Full-benefit dual-eligibles receive comprehensive Medicaid coverage, while partial-benefit dual-eligibles receive help with their Medicare premiums and cost-sharing through one of four Medicare Savings Programs.
How Do I Qualify for Medicare?
Medicare coverage is for adults 65 and older and those with certain qualifying medical conditions or disabilities. At age 65, you automatically qualify.
After you sign up for Medicare, you will begin paying monthly premiums. Medicare premiums are based on your income and your work history.
The eligibility requirements for Medicare Part A (hospital coverage) are very simple. If you or your spouse worked and paid Social Security taxes for ten or more years, your Medicare Part A premium is free. If not, you will pay a monthly premium for Part A.
With Part B, all Medicare beneficiaries pay a monthly Part B premium, however, if you are a high-income earner you will pay a little more. You can find the current schedule on this Medicare.gov page.
How Do I Qualify for Medicaid?
Medicaid eligibility is primarily based on the Federal Poverty Level (FPL). However, your state may also have its own income guidelines. Some states have different income limits than federal guidelines.
The FPL income level for an individual this year is $13,590. Income levels go up from there based on the size of your household. Alaska and Hawaii have higher FPL levels, $16,990 and $15,630, respectively.
To determine eligibility for Medicaid, states generally use a percentage multiple of the FPL guidelines (for example, 133 percent or 185 percent of the guidelines).
To qualify, you’ll need your social security number and those of your minor children (if applicable). You’ll also need proof of income and whether or not you receive other government assistance such as WIC or Food Stamps. You’ll also want documentation of any disability you or your children may have.
You can apply for Medicaid either online through the Health Insurance Marketplace or through your state’s Medicaid agency. Medicaid also includes the CHIP program which is the program for children in low-income households.
Even if you don’t qualify based solely on your income, assets, or disabilities, you may still qualify for aid.
What’s the Difference Between Medicare and Medicaid?
Medicare is health insurance for people aged 65 and older and individuals with certain disabilities. Medicaid is health insurance for low-income individuals and families.
Medicare has monthly premiums, deductibles, copays, and other costs. People with Medicare pay about 20% of all major healthcare costs, and Medicare pays the rest. Medicare does not cover routine healthcare costs, including prescriptions, dental, vision, and hearing.
The costs for people enrolled in Medicaid are minimal. And, Medicaid covers both major medical and routine healthcare costs, including prescriptions.
When an individual qualifies for both Medicare and Medicaid, Medicare is the primary payer of all Medicare-covered services. Medicaid assists with Medicare’s costs, including premiums, deductibles, copays, and prescriptions.
Can I Have A Medicare Advantage Plan with Medicaid?
In a growing number of counties, there are Medicare Advantage plans (Part C) designed explicitly for Medicare beneficiaries who also qualify for Medicaid. They are called dual-eligible Medicare Advantage Special Needs Plans, or just D-SNP plans for short.
These unique plans consider the special needs of low-income Medicare beneficiaries in the region they serve. They do not have the same cost-sharing requirements (i.e., copays) as normal Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B)..
Some smaller, rural counties may not have D-SNP plans but will have a local Medicaid plan. You will need to call your local Medicaid office to learn more.
You can use our search tool to compare Medicare Special Needs plans in your area:
Find Plans in your area with your ZIP Code
What are Medicare-Medicaid Plans (MMPs)?
A Medicare Medicaid Plan is a Medicare Advantage private health plan that provides coordinated Medicare and Medicaid benefits for dually eligible individuals. The goal of an MMP is to simplify how dual-eligible individuals gain access to the care they are entitled to under both Medicaid and Medicare.
MMPs differ from SNPs in that they have stronger coordination of Medicare and Medicaid benefits. With an MMP, benefits are offered as a single plan in a three-way contract between CMS, the state Medicaid agency, and the health plan.
With a D-SNP plan, the health plan holds a contract with Medicare and a separate contract with the state Medicaid agency to provide benefits with different levels of integration.
Can I Keep My Original Medicare Benefits and Have Medicaid?
Dual-eligible beneficiaries can keep their Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. (hospital insurance) and Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. (medical insurance) and apply for a Medicare Savings Program. You do not need to qualify for full Medicaid benefits to get assistance.
There are four types of Medicare Savings Programs:
- Qualified Medicare Beneficiary (QMB) Program
- Specified Low-Income Medicare Beneficiary (SLMB) Program
- Qualifying Individual (QI) Program
- Qualified Disabled and Working Individuals (QDWI) Program
If you answer yes to these 3 questions, call your State Medicaid Program to see if you qualify for assistance in your state:
- Do you have, or are you eligible for, Medicare Part A?
- Is your income at, or below, the federal poverty standard?
- Do you have limited financial resources (approximately $7,500 for individuals or $11,500 for couples)?
If you qualify for the QMB program, SLMB, or QI program, you automatically qualify to get Extra Help paying for your Medicare prescription drug coverage (Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each...).
Can I Have a Medicare Supplement and Medicaid?
Medicare Supplement insurance companies cannot sell you a Medigap policy if you are receiving assistance through your state Medicaid program. Nor is it needed. Your Medicaid program benefits provide more coverage than a Medicare SupplementMedicare Supplements are additional insurance policies that Medicare beneficiaries can purchase to cover the gaps in their Original Medicare (Medicare Part A and Medicare Part B) health insurance coverage. plan.
Can I Get Help with My Prescription Drugs?
For many Medicare beneficiaries, prescriptions are their number one healthcare cost. There are several ways that people with both Medicare and Medicaid benefits can get extra help with their prescriptions.
The first and most important way is to apply for the Social Security Administration’s Extra Help program. This program provides low-income subsidies (LISSocial Security's Low-Income Subsidy (LIS) program helps Medicare beneficiaries pay for their Medicare Part D prescription drugs by paying some of the costs. Also known as "Extra Help", beneficiaries who qualify for LIS receive premium...) to those who need them.
These subsidies can help you pay all or part of the monthly premium for a Medicare Part D plan, and is worth about $5,000 per year. You will need to call Social Security directly at 1-800-772-1213 to check your eligibility.
If you are able to enroll in a dual-eligible Special Needs Plan, your D-SNP will include prescription drug coverage. With a D-SNP plan, enrollees pay small copayments, but there’s no annual deductible. Use our SNP directory to discover enrollment opportunities in your area.
Find Plans in your area with your ZIP Code
What if I need to be in a Nursing Home?
Medicare covers most of the costs associated with a skilled nursing facility after an inpatient stays in the hospital. If you have both Medicare and Medicaid, a stay at a skilled nursing facility will cost very little.
After inpatient treatment, many patients need more outpatient care in the home setting. To learn how to get financial assistance for home health care, read How to Qualify for Home Health Care & Get Financial Assistance.
If you require assisted living because you are no longer able to live independently, read Does Medicare Cover Assisted Living Costs? What About Independent Living?
If you need long-term care and have limited resources, Medicaid can help, however, strict asset limits do apply. We have a complete guide to long-term care if you need it.
Citations & References:
- Contact Your State With Questions | Medicaid
- Medicaid.gov: the official U.S. government site for Medicare | Medicaid
- Medicaid.gov: the official U.S. government site for Medicare | Medicaid
- Medicare.gov: the official U.S. government site for Medicare | Medicare
- Medicare Savings Programs | Medicare
- SNF Care Coverage
- Disability Benefits | SSA
- Substantial Gainful Activity
- Social Security Online – Medicare Information