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Being Dual-Enrolled in Medicare & Medicaid, And How You Can Be Dual-Eligible for Both

What is Dual Enrollment? Dual enrollment refers to the situation where a person can qualify to enroll in both, Medicare as well as Medicaid. It will include Part A, Part B and Part D portion of Medicare.

For the uninitiated, what these plans mean is that they can take advantage of hospital stay, doctor visits as well as prescription drug benefits offered by the plans. It is estimated that there are over 9 million people in the US who are qualified to get Dual enrollment. In most circumstances, Medicare is the main provider of health insurance. However, Medicaid was put in place to cover some of the things Medicare did not cover.

Looking Into the Fine Print

What needs to be kept in mind is that Medicaid is a little bit different from Medicare. This is because Medicaid benefits can change according to the state. Each state will have their own rules regarding what exactly is covered and who all can qualify. Having said that, there are some basic things Medicaid is expected to cover no matter what state it is. Examples of this basic coverage would be nursing facility services, inpatient and outpatient costs, and home health services. When one goes into the details of what each plan gives, one will notice that there are times when the two will overlap.

Who Qualifies For Dual Enrollment?Related image

In order to qualify for dual enrollment, the person must come under one of the following categories: A senior who has low income and assets. By low income, it is meant that their income should be at or below the national poverty level. This group is the most common to enroll. When married couples are involved then there are more things they will look into, such as total assets. In some cases, one spouse may qualify but the other one will not.

Qualifying with a Disability

The second most common are young people who have disabilities and also come from low-income families. However, in order for young people to be qualified, they may need to go the extra mile to prove that they need it, compared to senior citizens. This usually means the applicant’s health is so bad that they need to stay in a skilled nursing home. No matter whether the applicant is young or old, they will need to qualify for Medicare Part A and B plans. Again, this will depend on the state in which they live in. There are Medicaid plans the applicant will have to qualify for before enrolling in Dual Plans. They are as follows:

  • Medicaid Special needs
  • Specified Low Income Medicare Beneficiary or SLMB plan
  • Qualified Medicare Beneficiary or QMB plan
  • Qualified Disabled Working Individual or QDWI plan

An individual who qualifies for Dual enrollment can choose their coverage according to the Medicare Advantage Plan. This means the dual plan will first be paid by Medicare. The reason for this is because Medicaid is generally the payer of last resort, in most instances. The only exception to this is when the applicant needs a service not covered by Medicare.

Things to Look Out For

What history has shown is that coordination between Medicare and Medicaid has not been very good. There is an element of “the right-hand does not know what the left hand is doing” scenario. A part of the reason for this is because of the aforementioned differences in individual states when it comes to Medicaid. It is not uncommon for medical practitioners to bill using only Medicare, and not Medicaid. On top of all this, Dual Care is the most expensive of all medical plans.

Signing Up for Dual EnrollmentImage result for Dual-Enrollment in Medicare & Medicaid illustration

For most people, especially seniors, applying for Dual Enrollment plans can be very confusing. Figuring out what each person is qualified for is a daunting task for most people. Some people in order to simplify things will go through an agency, such as the social services department, that specializes in this. This is a good idea since they can walk applicants through the process. Those who decide not to go this route will often time just combine Medicare and Medicaid under one policy. But overall, using an agency to help out is the best option. Apart from making things easier, they may find things the applicant is qualified for, that the applicants themselves may not have known.

Should You Dual Enroll?

There is also the future to think about in all this. If an applicant does not qualify at the present moment, then they may end up qualifying sometime in the future, especially if their financial situation changes. So, unless they know for sure they are going to get more money and assets in the future, it is well worth a try to get on board.

How You Can Be Dual-Eligible

Medicare and Medicaid are not exclusive programs. An overlap occurs in many situations. This happens when a person is eligible for Medicare but still has an income that falls within the Medicaid guidelines. There are critical facts about dual enrollment in Medicare, in addition to facts about dual-enrollment in Medicaid.

Dual Eligibility 

Dual eligibility can be accomplished in various ways. The eligible income of the applicant is vital to determining if they can receive both Medicare and Medicaid. There are a few different plans that you can qualify for to get Medicaid after you already qualify for Medicare. Facts about dual enrollment in Medicare will show that this eligibility is not only for the elderly, it is also for the disabled, many who receive social security disability insurance (SSDI) and are aged 19 to 64. There are various programs that will automatically qualify a person for being dual eligible for Medicare and Medicaid. Here are some facts about dual-enrollment in Medicaid and what financial requirements are needed.

Qualifying Medicare Beneficiary (QMB)

This program is designed for people within a certain income range. Usually, the range is for an individual with an income limit (100% of the Federal poverty level (FPL)) of $1,025 or a married couple with an income limit of $1,374. There is also a stipulation to the number of resources the person or couple must be below. This program helps with premiums of Medicare Part A and Part B, in addition to deductibles, copayments, and coinsurance. When you are dual enrolled, Medicare pays the bill first and then Medicaid pays the copayments, so the out-of-pocket of the subscriber is much lower.

Specified Low-Income Medicare Beneficiary (SLMB)

This program has similar income limits (100% FPL to 120% FPL) as the QMB, but they are slightly higher. As far as resource limits, they are also a bit higher than the QMB program. This program only helps pay Medicare Part B premiums.

Qualified Individual (QI)

Again, the income limits (120% to 135% FPL) continue to go up. With this program, the married couple income limit is $1,872, and the individual is $1,386. The resource limits are $7,560 for the individual and $11,340 for a married couple. Again, this program only pays for Medicare Part B premiums.

Qualified Disabled and Working Individuals (QDWI)Image result for Qualified Disabled and Working Individuals (QDWI) illustration

This program helps pay for Medicare Part A premium. It is designed for people who are working and under 65 years old, you meet the income limits of your state, and you are not getting medical assistance. The income limits (200% FPL) for this program are much higher than the other programs, but the resource limit is relatively low.

Full Benefit Dual Eligible (FBDE)

This program is designed for people whose income or resource limit may not qualify them for one of the other programs. However, these are people who have significant medical bills and expenses.

Medicaid Eligibility 

Eligibility into Medicaid is based on income calculated using the Modified Adjusted Gross Income (MAGI). This system decides what income is considered when calculating a person’s financial eligibility. Only the taxable amount of social security income is used to determine the financial status of the individual or family. MAGI takes a person’s adjusted gross income, taxable social security benefits, tax-exempt interest, and excluded foreign income to come up with the final determination.

Where To Turn

Being dual eligible for Medicare and Medicaid can be confusing. There are a bunch of rules and facts about dual enrollment in Medicare. Sometimes, it is easier to seek out organizations that are experts in Medicare and Medicaid. They may be able to guide you and determine which benefits you are eligible for. There are many resources for those eligible for Medicare. People either over age 64 or disabled aged 19 to 64 can qualify. Medicare itself can be very confusing because a person can choose to either keep straight Medicare or choose an advantage plan. Straight Medicare will let you go to any doctor who takes it (which is usually many more than the advantage plans) and you do not need referrals. The drawback is that you are required to pay a 20% coinsurance. Alternatively, if you choose an Advantage plan, it works like an HMO or PPO plan. Therefore, you have lower copays. However, you will probably need a referral and there are various plans to choose from. The various plans will differ in copayments and coverages. So, you need to do your research and find out which one is best for you.