For nearly 12 million 'dual eligibles,' Medicaid is lowering
Medicare's coverage costs, extending access to long-term care – or both
Steve Anderson
June 10, 2020
Key takeaways
·
In 2018, about 20 percent of
Medicare beneficiaries were also enrolled in Medicaid.
·
Dual beneficiaries are
Medicare enrollees who are eligible for
Medicaid benefits or for Medicaid’s help in paying for Medicare premiums, cost
sharing or both.
·
The state where
you live affects your coverage and benefits as a dual.
·
Some Medicare enrollees
are automatically
enrolled in Medicaid by a state agency.
·
A skilled nursing facility
may help a Medicare
beneficiary enroll in Medicaid.
·
Some Medicare
beneficiaries may be eligible for Medicaid assistance but don’t end up
receiving it.
·
Some duals are
enrolled in private plans automatically; other receive solicitations from
carriers.
·
Enrollment in a
private plan may not cost more for a dual – and may save
duals money.
·
Private plan
choice can affect your healthcare experience, including your
choice of providers.
·
There’s a long list of
experts who can help duals
better understand dual eligibility and private plan options.
If you’re familiar
at all with Medicare, you know that while the program promises healthcare
security for millions – including the vast majority of Americans age 65 and
older – Medicare is also riddled with coverage gaps.
Since Medicare was
passed into law, a range of private coverage
options – Medicare
Advantage, Medigap and Medicare Part D –
were created to help enrollees deal with those coverage gaps and manage the
program’s costs. But today, a vast cross section of Medicare enrollees also receives
coverage and financial support through another well-known safety net: Medicaid.
In 2018, an
estimated 12.2 million
Medicare beneficiaries – about 20 percent of all enrollees – were also enrolled in
Medicaid and are known as dual-eligible beneficiaries or dual-eligibles. And
while you might not hear that term often – or at all – it’s worth your time to
understand what it means to have both Medicare and Medicaid
(especially if you or a loved one is part of the “Medicare-Medicaid”
population).
Why are Americans in
both Medicare and Medicaid?
If you’re enrolled
in both Medicaid and Medicare, it’s because your income and assets are low
enough that you’ve either qualified for help covering some of the costs that
Medicare beneficiaries incur, or qualified for full coverage under both
Medicare and Medicaid, with Medicaid picking up the tab for Medicare premiums
and out-of-pocket expenses and certain services that Medicare does not cover.
States have different
income and asset limits for their different Medicaid programs – including
limited Medicaid benefits that pay for Medicare’s premiums and/or cost sharing
(Medicare Savings
Programs). Because these standards vary, you should contact
resources in your state to see which program(s) you might qualify for and for
help applying.
If you do have some
sort of additional Medicaid coverage, you fall into one of two main categories
of dual-eligibles:
“Full-benefit
dual-eligibles” have Medicare and receive a full array of benefits under Medicaid.
If you’re a
full-benefit dual-eligible, Medicare will be your primary source of coverage
for medical services, with Medicaid helping pay Medicare premium costs and
co-pays.
Medicaid also helps
“full duals” by covering services that Medicare doesn’t cover, such as
long-term care (explained later in this article).
A smaller segment of
dual-eligibles – “partial duals” – qualifies to have Medicaid pay some
but not all expenses, such as Medicare premiums and/or cost-sharing. So if
you’re a “partial dual,” you would not be covered for Medicaid-only services;
rather, you’d receive Medicaid’s help covering what could otherwise be your
cost sharing for Medicare-covered services.
Generally, “partial
duals” have income and assets that may be low – but not low enough to qualify
for full Medicaid benefits in their state.
You can find out if
you may qualify for Medicaid by contacting your Medicaid office. If you are
applying for Medicaid, states usually have 45 days to process your application
(but they have 90 days to do this if you’re disabled). An Internet search for
Medicaid offices in your state should provide the number to call – but make
sure you have reached a government office before sharing any personal
information.
The Centers for
Medicare and Medicaid Services (CMS) also maintains a list of state
agencies that oversee Medicaid.
You’ll generally
qualify for partial Medicaid benefits through the MSP if your income is less
than 135 percent of the federal poverty level and you have limited savings.
This is equal to an annual income of $17,226 for single beneficiaries
and $23,274 for couples in 2020. The federal asset limit for MSPs is $7,860
for individuals and $11,800 for couples – although states can have a higher
asset limit or choose not to have any asset test.
You’re automatically
eligible for Medicaid in a majority of states if you receive
Supplemental Security Income (SSI). Some states automatically enroll
you in Medicaid if you have SSI – but in other states you’ll have to
apply for it yourself. You’ll usually qualify for Medicaid due to your
financial circumstances if you’re poor enough to receive SSI benefits – even if
you’re not automatically eligible under your state’s rules. (Although this
is not the case in every state, and Connecticut, New Hampshire, Hawaii,
North Dakota, Illinois, Oklahoma, Minnesota, Virginia and Missouri have at
least one Medicaid eligibility criteria that is more restrictive than the SSI
program.)
Medicaid’s income
rules for beneficiaries without SSI also vary from state to state,
although income limits are usually less than 100 percent of the federal poverty
level. Some states also allow you to qualify for Medicaid by “spending
down” your monthly income to a specific amount. Single individuals
usually need to have less than $2,000 in savings (and that
limit is $3,000 for couples).
A majority of states
also allow beneficiaries needing an institutional level of care to
qualify for Medicaid with incomes up to 300 percent of the SSI federal
benefit rate (which equals $2,349 per month in 2020).
The state where you
live matters
Coverage and
benefits for dual-eligible beneficiaries vary widely – both because of each
individual’s financial situation, but also often because of the state where the
beneficiary resides.
States are required to
cover certain services for Medicaid recipients, including
skilled nursing facility or hospice services. But states can go above and
beyond these “mandatory levels” to cover expenses such as long-term care
services provided in your home.
For this reason,
alone, it’s important to do your homework and get advice tailored to your
specific situation.
How did I get
enrolled in both Medicare and Medicaid?
The route to
enrollment in both programs varies, but typically, dual-eligibles start out
enrolled in Medicare, and then gain the additional coverage through Medicaid on
the basis of income/assets or life circumstances (such as a severe disability).
These dual-eligibles qualify because they or someone else realizes the beneficiary
also needs Medicaid.
You could be
enrolled in Medicare, for instance, and then be automatically also enrolled in
Medicaid by a state agency, which might determine your Medicaid eligibility
based on your enrollment in another program, such as the Supplemental Nutrition
Assistance Program (SNAP) or Supplemental Security Income. (At some point, you
may get a notification by mail that you’ve been enrolled in Medicaid.)
Another catalyst for
Medicaid enrollment is often a skilled nursing facility (commonly referred to
as a nursing home). Because Medicare coverage in these facilities is generally
limited to people who need “skilled care” (such as rehabilitation from an
injury or accident) and limited to those who need rehab in an institutional
setting, these facilities may apply for Medicaid on behalf of patients who
exhaust Medicare’s coverage.
Unless you also need
skilled care, Medicare will never pay for custodial care – that is, help
with daily activities that
can be performed by an “unskilled” professional such as bathing or getting
dressed. (Medicare may pay or provide limited help with these items while you
are also receiving skilled care.)
Unlike
Medicare, Medicaid can help pay for custodial care in a
nursing facility or at home. Again, eligibility rules and the extent of your
coverage can vary by state.
Situations that lead
to enrollment in both programs
More specifically,
how might a beneficiary of one program also end up enrolled in both? The
following are just a few hypothetical situations:
·
Your grandmother is in a skilled nursing facility recovering from
an injury and exhausts her Medicare coverage. Once she can’t afford to continue
paying on her own, the facility may help her apply for Medicaid. Your
grandmother may also work with an elder law attorney to make the application
and protect some of her remaining savings or assets. (She could also work with
the attorney to plan for Medicaid in advance.)
·
You’re receiving Medicaid coverage through HealthCare.gov and are
nearing age 65. Your state becomes aware of your birth date and impending
eligibility for Medicare, and enrolls you in Medicaid coverage based on your
new status as being Medicare-eligible while having limited income and assets.
(Conversely, some Medicaid recipients actually lose their benefits under the
different rules that apply once they’ve qualified for
Medicare.)
·
You’re enrolled in a Medicare Savings
Program – for help with Medicare premiums and other costs – and
your state Medicaid agency automatically enrolls you in Medicaid based on a
review of your assets and income. You might also qualify for full Medicaid
benefits for a shorter time period based on a Medicaid
“spend-down.” (This is also referred to as a “medically needy
program.”)
Can I be eligible
but not receiving ‘dual’ benefits?
Yes. Some Medicare
beneficiaries – especially low-income seniors – qualify for Medicaid assistance
but don’t end up receiving it because they either don’t realize they qualify or
they aren’t able to navigate the lengthy application and renewal processes.
If you’re not
certain whether you qualify, you should contact your local Medicaid office or
one of the resources listed at the end of this article.
Extra coverage for
‘dual-eligibles’
If you were
surprised to learn that Medicaid works hand in hand with Medicare, you might
also be surprised to know that there’s a long list of government-sponsored
private plans that provide coverage to dual-eligibles.
Sometimes your state
will require you to enroll in one of these private plans; other times you’ll
have the option to not enroll. In either case, your state and the federal
government (Medicare) together pay most or all costs associated with your
enrollment.
Unlike “regular”
Medicare and Medicaid, privately administered plans can offer you additional
benefits such as care coordination or case management. In some cases, these
government-administered private insurers offer you a way to receive coverage
under Medicare and Medicaid (including long-term or home care) through a single
plan rather than several different ones. While the government may pay for the
plan’s costs, the plan is run by a private insurer.
The plans vary a
lot: Some cover a wide range of benefits – including all of your medical,
hospital prescription drugs, and home or nursing care. Other plans only cover
specific portions of your care, such as Medicaid’s home care benefits. The
availability of these private plans also depends on the state where you live,
meaning that some dual-eligibles have more plan options than others.
·
One of the most common types of health plans for Medicare-Medicaid
enrollees is a Dual Eligible
Special Needs Plan (D-SNP), which can have added benefits
compared with regular Medicare Advantage plans. (A D-SNP is actually a type
of Medicare
Advantage plan with special benefits geared toward helping
enrollees with lower incomes or higher care needs.)
·
In many states, consumers must enroll in private Medicaid plans
for Medicaid long-term care or home care services. If you have one of these
plans, you’ll continue to receive your other Medicare and Medicaid benefits the
way you have been receiving them. These plans are referred to as Managed
Long-Term Services and Supports plans (MLTSS), but have different names
depending on your state and the private insurers offering the plans.
Enrollment in
private plans
·
You might be automatically transitioned into a D-SNP if you
currently have a regular Medicare Advantage (MA) plan and your MA insurance
company thinks you could benefit from its D-SNP coverage. (Some states offer D-SNPs
that coordinate with Medicaid to cover your care. In addition, states may offer
plans similar to D-SNPs that include Medicare, Medicaid and long-term care
services. But as a dual-eligible, you only have to have a single health plan.)
·
You might end up in an MLTSS plan if you qualify for a certain
amount of home care and your state decides to enroll citizens like you in
private coverage plans rather than directly pay for the Medicaid long-term
care. (Remember that the names of these plans may vary – as well as the type
and amount of care they provide.) You may also be auto-enrolled in one of these
plans. In that case, you might be able to opt out of that specific plan and
into other coverage. Your state’s rules may vary.
·
Often, people with Medicare and Medicaid will receive mail
notifications and solicitations about enrollment in these and other plans. Some
notifications may require you to take action to ensure you get a plan that fits
your care needs and gives you access to providers you want.
How does having both
programs affect my costs?
In addition to
covering expenses that Medicare will not cover – such as long-term care –
Medicaid can pay for your co-pays and deductibles for Medicare-covered
services.
A plan may be
privately administered, but if you have both Medicare and Medicaid,
you may not have to pay more for this coverage than you did before you
enrolled. This is because the government pays for most or all of your
coverage. (You also may not have a choice but to enroll, depending on the
type of plan and your state’s own rules. Follow the information in this article
to ensure you choose a plan that fits your needs. It might even save you
money.)
Often, a privately
administered dual plan can save you money by covering expenses that regular
Medicare doesn’t cover (for example, over-the-counter drugs or additional
benefits for hearing aids). That said, regular state-run Medicaid can also
offer these types of benefits.
Many states contract
with private companies to provide Medicaid and dual-eligible plans – and most
of the time, the plan’s premium costs are completely paid for on your behalf.
But be sure to ask about costs before enrolling in any private health plan.
Additional
considerations
Just like with any
other health insurance coverage, the plans you choose for your coverage as a
dual-eligible will impact and potentially limit or improve your healthcare
experience – including your choice of healthcare providers, whether you need to
ask permission before seeing a specialist, or how you receive your home care.
These plans
typically change benefits each year, so it pays to watch for
notifications from your carrier.
·
Plans vary from state to state. In addition, your
state may have multiple types of plans and programs to provide coverage for
dual-eligibles. For example, states such as New York, Virginia and Minnesota
offer special Medicare-Medicaid Plans (MMPs) that integrate all your benefits
under both programs. (These MMPs have different names in different states.)
·
You can usually change plans. If you have Medicare
and Medicaid, a Medicare Savings
Program, or Extra Help,
you can change Medicare health plan as many times as you want each year. But,
as always, it’s better to choose the right plan(s) from the start and, if
possible, avoid being enrolled in coverage you need to change later.
·
Some states are more restrictive. All plans have
enrollment rules and deadlines, but your state may have stricter rules –
especially for the types of Medicaid MLTSS plans that cover only long-term
care.
·
You need to watch for changes. You should be
watching your mail for notifications about enrollment, premiums, benefit
changes, etc.
Where to turn for
help
Because there’s so
much variation in plans geared toward dual-eligibles, it behooves you to do
your homework – and that will include seeking help from experts who can analyze
your particular situation and give you advice tailored to your needs. Among the
resources available to you:
1-800-MEDICARE call center
representatives also have access to enrollment information, resources available
in your state, and can help with some Medicare-related enrollment changes.
These reps will be able to tell you what Medicare or duals private plan you
have, but they can’t make changes or recommendations regarding MLTSS coverage
(which is a Medicaid-only service).
Legal aid societies and similar
organizations, many of which operate healthcare hotlines to assist with
coverage questions. Trained attorneys and advocates can give specific advice
tailored to what’s happening in your state. They can also discuss income,
assets, eligibility and other important issues.
If you call your
Legal Aid or SHIP, you can begin your conversation by stating that you’re
looking for help with Medicare’s costs and/or long-term care. You can ask to
talk with someone to help you determine whether Medicaid or a Medicare Savings
Program could save you money or offer additional benefits.
State Health Insurance
Assistance Programs (SHIPs) are Medicare counseling services in each state. These
trained counselors should be able to refer you to local resources on Medicaid
benefits if they can’t answer your specific questions themselves. Our state guide to Medicare includes
SHIP listings within each state overview.
Private insurance
brokers may specialize in Medicare private plans, some of which are
tailored to the needs of dual-eligibles. Be careful, though, to work with your
insurance broker to consider all available Medicare plans so you pick the one
that meets your coverage needs – and saves you the most money.
Enrollment
brokers are state-contracted call centers that facilitate enrollment in
the various plans that cover recipients of both Medicaid and Medicare. This
hotline is typically the only one where customer service representatives (CSRs)
can make enrollment changes for you. You can search online for your state’s
hotline, but also make sure to check with the appropriate legal aid society’s
healthcare group for unbiased advice.
Your state’s call
center (which will have a different name in your state) or Medicaid office may
have answers to more basic questions (such as whether you have Medicaid or which
plan you have).
Family or estate
planning attorneys can answer questions about qualifying for Medicaid based on
your assets and/or income. They may be able to help you plan for your
healthcare needs using a Special Needs Trust. You can find a legal referral in
the elder law section of your state bar association’s web site.
https://www.medicareresources.org/medicare-benefits/how-medicaid-supports-1-in-5-medicare-enrollees/
