Medicare beneficiaries who are also eligible for Medicaid are considered dual-eligible. If you are Medicare dual eligible, you may qualify for a Medicare D-SNP (Dual Special Needs Plan), which is a type of Medicare Advantage plan.

Medicare and Medicaid are both public health insurance programs. If you are dual-eligible, you can have both Medicare and Medicaid coverage at the same time.

Two of the key differences between Medicare vs. Medicaid includes:

• Medicare is for people age 65 and over and for certain people under 65 who have a qualifying disability. Medicare eligibility is consistent for everyone across the U.S., no matter what state you live in.
• Medicaid is for people of any age who meet certain income qualifications. Medicaid is administered by state governments, and eligibility requirements can differ between states.

Who is dual-eligible for Medicare and Medicaid?

To be Medicare dual eligible, you have to meet the requirements for Medicare and your state’s Medicaid program.

To be eligible for Medicare, you must:

• Be at least 65 years old or have a qualifying disability
• Be a U.S. citizen or permanent legal resident
• Be eligible for benefits through Social Security or the Railroad Retirement Board

Medicaid provides health insurance to low-income individuals and families, children, and pregnant women. The best way to find out if you are eligible for Medicaid is to visit your state’s Medicaid website.

If you’re eligible for Medicaid and want to find out if you’re also eligible for a dual-eligible Medicare Medicaid plan, you can call and speak with one of our licensed insurance agents to find out if you’re eligible. An agent can help you compare the plans that are available where you live and find out what they may cover, which could include benefits like prescription drugs and other services.

Dual Eligible Medicare Advantage Plans

Special Needs Plans (SNPs), created by Congress in 2003, are a type of Medicare Advantage (MA) plan that limits membership to people with specific diseases or characteristics. Dual Eligible Special Needs Plans (D SNPs), one type of SNP, enroll only individuals dual-eligible for Medicare and Medicaid.

You can get your Texas Medicare benefits through Original Medicare, or you can choose a Medicare Advantage Plan. With Original Medicare, the government pays for your Medicare benefits when you get them. Medicare Advantage Plans, Part C of Medicare are offered by private companies that have been approved by Medicare. Medicare pays these companies to administer your Medicare benefits.

Medicare Advantage Plans combine coverage for the hospital (Part A) and doctor (Part B) visits all in one plan and are required to offer all the benefits included in Original Medicare (except hospice care which continues to be covered by Part A). However, many Medicare Advantage (Part C) plans also include prescription drug coverage and routine eye and dental care coverage not offered by Original Medicare.

Many Medicare Advantage (Part C) plans include prescription drug, vision, hearing, and dental coverage not offered by Original Medicare (Parts A & B). Additionally, each Medicare Advantage plan is required by law to feature an annual maximum cap on out-of-pocket costs, meaning once that limit is reached you will pay nothing for additional covered medical services.

If you join a Texas Medicare Advantage Plan, the plan will provide all your Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) coverage. They are completely different than a Medicare Supplement Insurance (Medigap) policy.

There are several types of Texas Medicare Advantage Plans:

Health Maintenance Organization (HMO) plans: In most HMOs, you may only go to doctors, other health care providers, or hospitals that are in the plan’s network, except in an emergency or urgent situation. You also need to get a referral from your primary care doctor for diagnostic tests or to see other doctors or specialists.

Preferred Provider Organization (PPO) plans: With a PPO, you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You pay more if you use doctors, hospitals, and providers outside of the network.

Private Fee-for-Service (PFFS) plans: PFFS plans are like Original Medicare in that you can go to any doctor, other health care provider, or hospital if they agree to accept the plan’s payment terms. The plan will determine how much it will pay doctors, other health care providers, and hospitals, and how much you must pay when you get care.

Special Needs Plans (SNPs): SNPs provide specialized and focused health care for specific groups of people, like those who have both Medicare and Medicaid, live in a nursing home, or have certain chronic medical conditions.

HMO Point-of-Service (HMO-POS) plans: These are HMO plans that may allow you to get some services out-of-network for a higher copayment or coinsurance.

Medical Savings Account (MSA) plans: These plans combine a high-deductible health plan with a bank savings account. Medicare will deposit money into the account (usually less than the deductible). You can use the money to pay for your health care services throughout the year. MSA plans do not offer any Medicare drug coverage. If you want drug coverage, you must join a Medicare Prescription Drug Plan, Part C of Medicare.

To be eligible to enroll in a Texas Medicare Advantage plan you must have both Medicare Parts A and B and live in the plan’s service area. 

You must continue to pay your Part B premium and pay one monthly premium for the services included in a Medicare Advantage Plan. Each Medicare Advantage Plan has different premiums and costs for services, so it’s important to compare plans in your area and understand plan costs and benefits before you join. Some may have a $0 premium.

Texas Medicare Advantage Plans must cover all the services that Original Medicare covers except for hospice care. Original Medicare will cover hospice care even if you are in a Medicare Advantage Plan. In all types of Medicare Advantage Plans, you will always be covered for emergency and urgent care. Medicare Advantage Plans must offer emergency coverage outside of the plan’s service area (but not outside the U.S.). Many Medicare Advantage Plans also offer extra benefits such as dental care, eyeglasses, or wellness programs.

Most Medicare Advantage Plans include Medicare prescription drug coverage (Part D). In addition to your Part B premium, you usually pay one monthly premium for both the plan’s medical and prescription drug coverage.

What type of coverage do you get if you are dual-eligible for Medicare and Medicaid?

There are two levels of coverage for beneficiaries who are dual-eligible:

• Full dual eligible
  Full dual-eligible refers to those who receive full Medicaid benefits and are also enrolled in Medicare.

  People who are fully dual eligible typically receive Supplemental Security Income (SSI) benefits, which provide cash assistance for basic food and housing needs.

  Qualifying as full dual eligible is based on your assets, which include checking and savings accounts, stocks, real estate (other than your primary residence), and vehicles (if you own more than one).

• Partial dual eligible
  Partial dual eligibility includes those who receive assistance from Medicaid to help pay for Medicare costs such as premiums, coinsurance, or deductibles.

  Partial dual eligibles fall into one of four categories of eligibility for Medicare Savings Programs.

A Medicare Savings Program (MSP) is a federally funded program administered within each state that helps lower-income people pay for Medicare premiums, deductibles, copayments, and coinsurance.

The four Medicare Savings Programs are outlined below.

Qualified Medicare Beneficiary (QMB) Program

This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments.

Eligibility requires:

• Income of no more than $1,094 per month for an individual in 2021, or $1,472 per month for a married couple
• Resources of no more than $7,970 for an individual in 2021, or $11,960 for a married couple

Specified Low-Income Medicare Beneficiary (SLMB) Program

The SLMB program helps pay for Medicare Part B premiums.

Eligibility requires:

• Income of no more than $1,308 per month for an individual in 2021, or $1,762 per month for a married couple
• Resources of no more than $7,970 for an individual in 2021, or $11,960 for a married couple

Qualifying Individual (QI) Program

Like the SLMB, the Qualifying Individual program helps pay for Part B premiums.

Eligibility requires:

• Income of no more than $1,469 per month for an individual in 2021, or $1,980 for a married couple
• Resources of no more than $7,970 for individuals in 2021, or $11,960 for married couples

Qualified Disabled Working Individual (QDWI) Program

The QDWI program helps pay for the Medicare Part A premium for certain people who meet one of the following criteria:

• Have a disability but are still working
• Lost their premium-free Part A coverage when they returned to work
• Are not receiving medical assistance from their state
• Meet the income and resource limits below
  • Income of no more than $4,379 per month for an individual in 2021, or $5,892 for a married couple.
  • Resources of $4,000 for an individual in 2021, or $6,000 for a married couple.

The income and resource limits listed above may increase in 2020. If your income and resources are slightly higher, you should still apply.

Medicare Dual Eligible Special Needs Plans (D-SNPs)

Another type of coverage that may be available to dual-eligible beneficiaries (depending on where you live) is a Medicare Dual Eligible Special Needs Plan (D-SNP).

A Medicare special needs plan is a certain type of Medicare Advantage plan that is designed for people with specific health conditions or circumstances.

A D-SNP is built for the specific needs of dual eligibles. All Medicare SNPs (including Medicare D-SNPs) provide prescription drug coverage.

How do Medicare and Medicaid work together?

For dual-eligible beneficiaries, Medicare serves as the primary payer, and Medicaid acts as the secondary payer.

That means Medicare is the first to pay for covered services and items, and then Medicaid will help pay some or all of your remaining costs.

What is PACE for Medicare and Medicaid?

Another Medicare and Medicaid program is PACE or Programs of All-Inclusive Care for the Elderly.

PACE helps older Medicare beneficiaries seek health care within their community, in their home, and at PACE facilities.

Some of the things that can be covered by PACE include:

• Adult day primary care
• Dental care
• Emergency services
• Home care
• Hospital care
• Lab and X-ray services
• Meals
• Medical specialty services
• Nursing home care
• Nutritional counseling
• Occupational therapy
• Physical therapy
• Prescription drugs
• Preventive care
• Respite care
• Social work counseling
• Caregiver training
• Transportation to a PACE facility when medically necessary

PACE is not strictly restricted to Medicare dual-eligible beneficiaries. You may be eligible for PACE with only Medicare or only Medicaid (or both).

However, you must meet all of the following conditions:

• Be at least 55 years old
• Live in the service area of a PACE organization
• Require a nursing home-level of care
• Be able to live safely in the community with help from PACE

What is CHIP?

CHIP is a Medicaid program for children and stands for Children’s Health Insurance Program.

CHIP benefits vary by state, but they generally include EPSDT, or Early and Periodic Screening, Diagnostic and Treatment services. This coverage is designed to ensure children receive proper early detection and related care so that health problems may be averted or diagnosed as early as possible.

CHIP programs in all states must provide well-baby and well-child care, dental coverage, behavioral health care, and vaccines.

CHIP serves uninsured children up to age 19 in families that earn too much money to qualify for Medicaid but still have trouble affording care.

What is Medicare Extra Help?

Extra Help is a federal program that helps pay for out-of-pocket costs related to Medicare prescription drug coverage. Extra Help is also known as the Medicare Part D Low-Income Subsidy (LIS)

The assistance that Medicare Extra Help may provide includes:

• Help to pay Part D premiums
• Lowered out-of-pocket costs of prescription drugs
• An annual Special Enrollment Period to enroll in a Part D plan or switch to a new one
• Elimination of Part D late enrollment penalties

You automatically qualify for Extra Help if you are enrolled in Medicaid, Supplemental Security Income, or a Medicare Savings Program.

You may still qualify for Extra Help if you are not enrolled in any of those programs but still have income and assets below a certain limit.

Find Medicare Dual-Eligible Special Needs Plans in your area

There may be Medicare D-SNPs available where you live, though they aren’t as widely available as other types of Medicare Advantage plans.

An Ashford Insurance licensed insurance agent can help you explore your Medicare Advantage plan options. Compare the plans that are available and find out what they may cover, which could include benefits like prescription drugs or dental care.

Remember, plan benefits can change from year to year. Make sure you understand how a plan works before you join.