As a family caregiver, you secure the best possible healthcare for your loved one. But with inflation, costs quickly add up, and not all treatments are affordable. Did you know that many older adults with disabilities are usually eligible for Medicare and Medicaid? Dual coverage offers comprehensive benefits with lower out-of-pocket costs.
Find out how Medicare and Medicaid work together, the eligibility requirements, extra assistance programs, and the main advantages of having both types of insurance.
Medicare and Medicaid are two government programs that provide health care coverage to millions of Americans. However, they have different eligibility criteria, benefits, and costs. Knowing the difference between Medicare and Medicaid can help you choose the best option for yourself or your loved ones.
Medicare is a federal program that covers people 65 or older, or younger people with specific disabilities or chronic conditions. Medicare has four parts: Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans), and Part D (prescription drug coverage). Medicare beneficiaries pay premiums, deductibles, coinsurance, and copayments for their services, depending on their chosen plan. Regardless of where you live, Medicare offers the same coverage and costs nationwide.
Medicare is the primary payer for most people who do not have coverage through other plans offered by employers, other groups, or unions, except under certain circumstances. Medicare covers major medical services like hospitalizations, doctor visits, lab tests, and prescription drugs. Medicare pays first on claims for covered services, and then the beneficiary or their supplemental insurance pays the remaining costs.
Medicaid is a joint federal and state program that covers people who have low income and limited resources. Medicaid eligibility and benefits vary by state, depending on the state's rules and budget. Medicaid covers services that Medicare does not, such as long-term care, dental care, and vision care. Medicaid beneficiaries usually pay little or no out-of-pocket costs for their services.
Medicaid is a joint federal and state program that covers people who have low income and limited resources. Medicaid is the secondary payer for beneficiaries eligible for Medicare, known as dual eligibles. Medicaid fills in gaps left by Medicare, such as covering some outpatient prescription drugs, Medicare premiums and cost-sharing, and long-term care services. Medicaid pays for these services after Medicare has paid its share.
Medicaid plays a more significant role in long-term care by covering nursing home care, home health aides, respite care, and other supportive services not generally included in Medicare. However, Medicaid eligibility and benefits for long-term care vary by state, depending on the state's rules and budget. Some states may have waiting lists or limited slots for specific long-term care programs.
Some people may qualify for both Medicare and Medicaid, known as dual eligibles. These people can benefit from both programs and receive more comprehensive coverage and lower costs. For example, Medicaid may pay for some or all of the Medicare premiums, deductibles, coinsurance, and copayments. Medicaid may also cover additional services that Medicare does not, such as personal care assistance, transportation, and home modifications. Dual eligibles can enroll in Medicare-Medicaid Plans (MMPs) that coordinate their benefits and services from both programs.
You must be enrolled in both programs to meet the dual Medicare and Medicaid eligibility requirements. To enroll in Medicare, you must be 65 or older or younger with specific disabilities or chronic conditions. To enroll in Medicaid, you must have low income and limited resources and meet your state's eligibility criteria.
Some people may automatically qualify for Medicare and Medicaid, such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). Others may need to apply separately for each program.
For dually eligible individuals with limited income and resources, Medicare Savings Programs assist in paying Medicare out-of-pocket costs like premiums, deductibles, and coinsurance.
Options include the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI), and Qualified Disabled and Working Individual (QDWI) programs. Each program has different income eligibility guidelines.
Being dually covered comes with many valuable advantages. Some of the benefits of having both Medicare and Medicaid are:
Family caregivers caring for a loved one with Medicare and Medicaid may face challenges and opportunities in managing their healthcare coverage and services. Here are some tips and resources that may help:
Dual Medicare and Medicaid coverage provides crucial benefits. As a family caregiver, evaluate eligibility and leverage available resources to guarantee your loved one gets the affordable, high-quality healthcare they need. Coordinating both programs results in your loved one accessing more comprehensive care for less out-of-pocket.
Know what's covered under Medicare versus Medicaid for proper billing. As a family caregiver, advocate for your loved one and make sure claims are submitted accurately based on primary versus secondary programs.
Medicare and Medicaid provide essential care, especially for those with limited incomes and resources. Knowing how these two public insurances coordinate coverage for your loved one is critical to accessing the full spectrum of healthcare services available.
