Adopting a Dual-Eligible Strategy for Affordable Healthcare

For millions of American Medicare beneficiaries, the cost of healthcare has become unaffordable.  More and more are realizing they may have to pay thousands of dollars in healthcare costs above and beyond what the federal government pays.

Depending on your Medicare plan, you may face copays, premiums, deductibles and coinsurance that vary depending on whether you select original Medicare or a Medicare Advantage plan.  Where you live, how healthy you are, how many prescriptions you take all determine the type of plan you can access.

For seniors who have low or very-low incomes and few assets, they may qualify to become what is referred to as “Dual-Eligible,” which means you can enroll in both Medicare and Medicaid. If your income is not quite low enough to qualify for full Medicaid benefits, you might be eligible for a Medicare Savings Program that can help you pay for some or all out-of-pocket Medicare costs.

Medicaid is funded by both the federal and state governments.  Each state has its own Medicaid eligibility requirements and determines what services it will cover beyond what original Medicare doesn’t.

In the past, Dual-Eligibles could make changes to their plans every single month of the year that would become effective in the following month.  However, since 2019 they can only make one change per quarter for the first three quarters (January – September) of the year.  During the fourth quarter they may not make changes but can participate in AEP.

What Medicaid covers vs Medicare

  • The Medicare Part B deductible.
  • The premium for Medicare Part B, which covers doctor visits and outpatient services.
  • The Medicare Part A (hospital insurance)
  • Both Medicare Part A and Part B copays and coinsurance.
  • The Medicare Part D (prescription drugs) premium, deductibles and copays.
  • Nursing home care and home-based long-term services and supports.
  • Depending on your state, Medicaid will cover benefits that Medicare does not, such as dental care, transportation to and from doctor visits, eyeglasses, physical therapy, and other services.

Qualifying for Medicaid

The eligibility requirements are different from state to state, but for the most part, states consider your annual income and financial assets when determining whether or not you qualify for Medicaid or some level of a Medicare Savings Program. Please check with you local Medicaid office for your state’s requirements.

If your state does financial testing, usually your home, car, burial expenses, life insurance and personal items are not counted as assets, but keep in mind that states can go back five years to determine your asset value. The value of assets you’re allowed to have and still be eligible varies from state to state. Some states have higher thresholds, while others don’t test.

Medicare Savings Programs

The Qualified Medicare Beneficiary (QMB) program helps pay for Part A and B premiums as well as deductibles, coinsurance and copays. This program has the lowest income threshold of the four.

The Specified Low-Income Medicare Beneficiary (SLMB) program helps pay only for Part B premiums, not the Part A premium or other cost sharing. If your income is too high to qualify for the QMB program, you might qualify for this one.

The Qualifying Individual (QI) program only helps pay for Part B premiums and no other cost sharing. If your income is too high for you to qualify for the QMB or SLMB programs, you might qualify for the QI program.

The Qualified Disabled and Working Individuals (QDWI) program only helps pay for Medicare Part A (hospital insurance) premiums. This program is designed for individuals with disabilities, under age 65, who are currently working and lost their premium-free Part A benefit when they began to work.

More information

For more information about Medicaid and Medicare check out the links below.  Each state has a State Health Insurance Assistance Program (SHIP) that provides counseling and help for Medicare beneficiaries.  The National Council on Aging has a benefits checkup website on Medicare and Medicaid.  And the Social Security administration has information on receiving help with your prescription drugs.

Visit Medicare’s website for more information on LIS and Dual Eligibility.
Visit the National Council on Aging benefit’s check-up website.
Visit the Social Security Administration’s website.
Visit the State Health Insurance Assistance Program website.