Medicare and Medicaid are two separate types of insurance coverage. If you qualify, you can enroll in both programs. Let’s learn about how they work together.
What is Medicaid?
Medicaid is a federal and state program that provides health coverage for certain people with limited income and assets. Each state runs different Medicaid-funded programs for different groups of people. Groups might include older people, disabled people, children, and pregnant people. All states also have Medicaid programs for people who need nursing home care, long-term care, and home health care. Some states have programs for people who don’t fit into any of these categories. Your income and assets must be below a certain amount to qualify for Medicaid. This amount varies from state to state and even from program to program.
Medicare and Medicaid can work together to cover your health care costs.
If you’re eligible for both Medicare and Medicaid, you can enroll in both. Some people may say you are “dually eligible.” Here are a few examples of how Medicaid can work with Medicare:
- Medicaid can provide secondary insurance. This means that Medicare would pay for your care first, and then Medicaid may cover any remaining costs like coinsurances and copays.
- Medicaid can help pay your premiums. In most cases, if you have both Medicare and Medicaid, you don’t owe a premium for your Medicare. A program called the Medicare Savings Program pays for it.
- Medicaid can help lower the costs of your prescriptions. Dually eligible people are automatically enrolled in Extra Help. This program helps with prescription drug costs.
- Medicaid can offer care coordination. Some states require certain Medicaid beneficiaries to enroll in Medicaid private health plans. These are called Medicaid Managed Care, or MMC, plans. These plans may offer optional enrollment into a Medicare Advantage plan designed to coordinate Medicare and Medicaid benefits.
People with Medicare and Medicaid have extra Medicare coverage options. If you are dually eligible, you may choose to enroll in a Medicare Advantage plan called a Dual-eligible Special Needs Plan, or D-SNP. These plans are designed to coordinate your Medicare and Medicaid coverage.
Medicaid programs vary by state.
The following programs are available to people with Medicare in every state who meet their state’s income, asset, and other guidelines.
- Aged, blind, and disabled Medicaid, or ABD Medicaid. ABD Medicaid covers a broad range of health services, including doctors’ visits, hospital care, and medical equipment. It may also pay for your Medicare cost-sharing.
- Medicaid home and community-based service, or HCBS, waiver programs. These waiver programs cover services to help you stay at home or in a community-based setting. For example, in an assisted living facility. Services may include personal care, homemaker services, case management, adult day care, skilled nursing care, or therapy services.
- Institutional Medicaid. This is Medicaid for residents in nursing homes. It covers room and board, nursing care, personal care, and therapy services. To qualify, you must need a nursing home level of care or meet state-specific functional eligibility criteria.
This month’s Medicare fraud reminder:
If you have Medicaid, you may also be enrolled in a Medicare Savings Program. This program pays your Medicare premiums. One type of Medicare Savings Program is called Qualified Medicare Beneficiary (QMB). If you have QMB, Medicare providers cannot bill you for any Medicare-covered services. If a provider does try to bill you, this may be called improper billing. This is true even if you see providers who do not accept Medicaid or who are in other states. Improper billing is not necessarily fraud, but it is still a type of error that requires resolution. You can be billed if you have a Medicare Advantage plan and see an out-of-network provider, or if you have Original Medicare and see an opt-out provider. It’s important to read your Medicare and Medicaid statements to ensure that the billing is correct. You cannot waive these protections and pay out of pocket for Medicare cost-sharing, like deductibles, coinsurance or copayments, and a provider cannot ask you to do this.
If you’re being improperly billed, speak with your provider first. Not all providers are familiar with QMB protections, so it may be an honest mistake. If you think you have experienced potential improper billing or Medicare fraud, errors, or abuse contact your local Senior Medicare Patrol (SMP) using the online SMP Locator or by calling 877-808-2468.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
If you think you have experienced potential Medicare fraud, errors, or abuse contact your local Senior Medicare Patrol using the online SMP Locator or by calling 877-808-2468.