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Tarrant County Dual-Eligible Medicare Plans

Medicare Advantage Made Easy

Tarrant County Dual-Eligible Medicare Plans

Most Americans understand that when they turn 65, Medicare will become their main health insurance plan. However, many Americans are less familiar with another health care program, Medicaid, and what it means if they are eligible for both Medicare and Medicaid. If you are dual eligible, Medicaid may pay for your Medicare out-of-pocket costs and certain medical services that aren’t covered by Medicare.

What is Medicaid?

Like Medicare, Medicaid is a health care coverage program funded by the federal government. It was established to help low-income individuals access health care coverage. Unlike Medicare, however, Medicaid is partially funded by state governments. This means that states have the flexibility to design their Medicaid programs to best meet the needs of their residents if the program meets the minimum federal guidelines. As a result, Medicaid eligibility, services, and cost-sharing (the amount you pay alongside your insurance) policies will vary state-by-state, while the Medicare program is generally consistent across all states.

How do I know if I qualify for Medicaid and Medicare?

Individuals currently enrolled in both Medicaid and Medicare are known as “dual-eligible beneficiaries” because they qualify for both programs. As long as you meet the federal qualifications for Medicare eligibility and the state-specific qualifications for Medicaid eligibility, you will qualify as dual-eligible. To qualify for Medicare, individuals generally need to be 65 or older or have a qualifying disability.

There are several levels of assistance an individual can receive as a dual eligible beneficiary. The term “full dual eligible” refers to individuals who are enrolled in Medicare and receive full Medicaid benefits. Individuals who receive assistance from Medicaid to pay for Medicare premiums or cost-sharing* are known as “partial dual eligible.”

*Cost-sharing is the amount of your health care that you pay out of your own pocket. Typically, this includes deductibles, coinsurance, and copayments.

What does Medicare and Medicaid pay for?

Medicaid is known as the “payer of last resort.” As a result, any health care services that a dual eligible beneficiary receives are paid first by Medicare, and then by Medicaid. For full dual eligible beneficiaries, Medicaid will cover the cost of care of services that Medicare does not cover or only partially covers (as long as the service is also covered by Medicaid). Such services may include but are not limited to:

  • Nursing home care
  • Care at an intermediate care facility
  • Long-term institutional care
  • Home health services
  • Personal care services (available in some states)
  • Other home and community-based services
  • Transportation services
  • Dental services (available in some states)
  • Eye examinations for prescription glasses (available in some states)

The financial assistance provided to partial dual eligible beneficiaries is outlined in the table above.

What are my options for receiving care as a Dual-Eligible?

People who qualify as dual-eligible have several options for how their care is delivered, although the number of available options will vary at the state level.

Original Medicare

Some Medicare beneficiaries may choose to receive their services through the Original Medicare Program. In this case, they receive the Part A and Part B services directly through a plan administered by the federal government, which pays providers on a fee-for-service (FFS) basis. In this case, Medicaid would “wrap around” Medicare coverage by paying for services not covered by Medicare or by covering premium and cost-sharing payments, depending on whether the beneficiary is a full or partial dual-eligible.

Medicare Advantage

Medicare Advantage plans are private insurance health plans that provide all Part A and Part B services. Many also offer prescription drug coverage and other supplemental benefits. Like how Medicaid works with Original Medicare, Medicaid wraps around the services provided by the Medicare Advantage plan and serves as a payer of last resort.

Medicaid Managed Care

Some states deliver care to the dual eligible population through Medicaid managed care programs. Others have established Medicaid-managed care plans specific to the dual-eligible population. Medicaid-managed care is similar to Medicare Advantage, in that states contract with private insurance health plans to manage and deliver the care.

In some states, the Medicaid-managed care plan is responsible for coordinating the Medicare and Medicaid services and payments. In other states, the payments related to Medicaid and Medicare are handled at the state/federal level, and the Medicaid-managed care plan is only responsible for coordinating Medicaid services.

Dual Eligible Special Needs Plans (D-SNP)

In some states, dual-eligible beneficiaries may have the option of enrolling in a D-SNP, which is different from a traditional SNP or Special Needs Plan. These plans are specially designed to coordinate the care of dual-eligible enrollees. Some plans may also be designed to focus on a specific chronic condition, such as chronic heart failure, diabetes, dementia, or End-Stage Renal Disease. These plans often include access to a network of providers who specialize in treating the specified condition. They may also include a prescription drug benefit that is tailored to the condition.