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Dual Eligibility for Medicare and Medicaid: Long-Term Care Requirements and Benefits

Medicare and Medicaid long term health benefits

In 2020, more than 62 million Americans were registered in the Medicare program, and nearly 69 million people were enrolled in Medicaid coverage. As of 2019, well over 11 million Americans were eligible for both Medicaid and Medicare. You might be wondering how someone can have both Medicare and Medicaid coverage and if you qualify for dual eligibility.

We’ll go over the eligibility qualifications for Medicaid and Medicare, the benefits available to you if you’re dual eligible, and other relevant information you might be interested in.

Distinguishing between Medicare and Medicaid

Applicants qualified for both Medicare and Medicaid programs are referred to as “Medicare-Medicaid enrollees” having dual eligibility. Since the terms Medicare and Medicaid can be easily confused, it is essential to distinguish between them. While Medicare coverage is a federal health insurance program for older adults and people with disabilities, Medicaid is a state and public medical assistance program for people of all ages who need financial support. Both programs provide several benefits, such as doctor visits and hospitalization, but only Medicaid offers long-term nursing care. Particularly relevant to the subject of this article, Medicaid also covers long-term care and supports in-home and community-based settings, such as one’s own home, an adult foster care residence, or an assisted living facility. However, beginning in 2019, Medicare Advantage plans (Medicare Part C) began providing some long-term home and area-based benefits. 

The CMS (the Centers for Medicare and Medicaid Services) is in charge of both the Medicare and Medicaid programs. CMS collaborates with state agencies to administer the Medicaid program in each state, whereas the Social Security Administration (SSA) applies for Medicare.

Definition of Dual Eligibility

Individuals must be enlisted in Medicare Part A (hospital insurance) or Medicare Part B (medical insurance) to be considered as dually eligible beneficiaries. People can choose Medicare Part C, also known as Medicare Advantage, as an alternative to Original Medicare Part A and B coverages. (Original Medicare program is managed by the federal government, whereas Medicare-approved private insurance companies manage Medicare Advantage plans.) Moreover, participants in the Medicare Advantage program receive Medicare Part A, Part B, and, in some cases, Part D, which provides prescription drug coverage.

Furthermore, individuals must be enrolled in either a full-service Medicaid program or one of dual eligibility Medicaid’s Medicare Savings Programs (MSPs). Medicaid full coverage includes hospital services (in-patient and out-patient), physician visits, laboratory facilities, and x-rays. Medicaid also covers nursing home care and, in many cases, limited personal care services in one’s home. While some states provide long-term care and community supports through their state Medicaid program, many states offer these aids through 1915(c) Medicaid waivers. (Be mindful that, unlike the state Medicaid program, Medicaid waivers are not entitlement plans, so there are enrollment caps.) 

Benefits of Dual Eligibility for Medicare and Medicaid Coverage

Individuals enrolled in both Medicare and Medicaid may benefit from significant medical care coverage and lower out-of-pocket costs. Medicare is always the primary payer (first payer) for Medicare-covered expenses such as medical services and hospitalization. If Medicare does not cover the entire cost, Medicaid (the secondary payer) will support the difference if the expenses are Medicaid-covered. Medicaid does offer some premiums that Medicare does not, such as home and community-based personal care assistance and long-term skilled nursing care (Medicare coverage limits nursing home care to just 100 days). As previously stated, some Medicare Advantage plans include the cost of some long-term care facilities and supports. Medicaid also helps cover the prices of Medicare deductibles, premiums, and co-payments through Medicare Savings Programs.

Long Term Care Benefits

Medicaid offers a wide range of long-term medical care benefits and supports, allowing people to age in place or in their community. Medicare does not provide these services, but in 2019, some Medicare Advantage plans began offering a variety of long-term home and community-based benefits. Long-term care benefits may include the following. This is not a complete list, and not all advantages may be available in all states. 

  • Adult Day Health / Adult Day Care
  • Assistance with Personal Care (at home, assisted living facilities, and adult foster care homes)
  • Transportation for Medical and Non-Medical Purposes
  • Care During a Break (to give the primary caregiver a break)
  • Meal Delivery / Congregate Meals
  • Skilled Nursing / Home Health Aide
  • Home Improvements (installing ramps, widening of doorways, adding pedestal ways to allow wheelchair access, etc.)
  • Personal Emergency Response Systems (PERS)
  • Chore Services / Housekeeping
  • Services for Companions
  • Services for Transition (from a nursing center back to home)
  • Treatments (physical, occupational, and speech)
  • Administration of Medication

Requirements for Eligibility

Medicare

As Medicare is a government program, eligibility is constant across the country. Persons must be Americans or legal residents who have lived in the United States for at least five years before applying for Medicare. Candidates must also be over the age of 65. There is no age limit for people who are disabled or have been diagnosed with Lou Gehrig’s disease (amyotrophic lateral sclerosis) or end-stage renal disease. Medicare eligibility is not based on income. As a result, there are no assets or income limits. 

Individuals are frequently not charged a monthly premium to receive Medicare Part A (hospitalization insurance). An individual (or their spouse) must have worked for at least ten years and paid into the Medicare program to be eligible for premium-free coverage.

Some people who have worked but have not met the complete work requirements may purchase Medicare Part A for $259 per month. If the total monthly premium is paid, it is around $471. (This figure, as well as the following Medicare statistics, are all current for 2021). The Part A in-patient hospital deductible is $1,484 per year. After the deductible is met, the patient must pay a cost-share (coinsurance) for health services. 

Enrollees in Medicare Part B (medical insurance) must pay a monthly premium of $148.50 in addition to a $203 annual deductible.

To be eligible for a Medicare Advantage (MA) plan, you must be enrolled in Medicare Part A and Part B coverage. The monthly premium varies depending on the program, but it is usually around $33 per month. Not all MA plans require a monthly premium, but those that do must be paid in addition to one’s monthly Part A and B premiums, if applicable. 

To receive long-term home and community-based services as a supplemental benefit under Medicare Advantage plans, medical/ functional requirements must be met.

Medicaid

Medicaid eligibility requirements are not as straightforward as Medicare eligibility requirements. This is because, as previously stated, Medicaid is a federal and state-funded program. While the federal government sets the program’s parameters, each state can set its own rules within these parameters. Even within the same region, there are numerous Medicaid pathways, each with its eligibility requirements.

Medicaid, unlike Medicare, has assets as well as income limits. In most states, as of 2021, private income limits for institutional Medicaid care (nursing home Medicaid coverage) and Home and Community-Based Services (HCBS) through a Medicaid Waiver are $2,382 per month. For a single applicant, the asset limit is usually 2,000 USD dollars. The income and asset limits differ from state to state. (See Medicaid Eligibility Terms by State for more information.) Candidates must also have a usable need for medical care, which typically corresponds to the level of care provided in a nursing home. Find out more

Medicare Saving Programs

The asset and income requirements for Medicare Savings Programs don’t follow the above financial criteria. Three MSP programs are explicitly designed for the elderly. Most states use the limits (current for 2021), but some regions use different guidelines. 

For example, Alaska, the District of Columbia (DC), Connecticut, Indiana, Massachusetts, Maine, and Hawaii have higher income limits, while Alabama, Arizona, DC, Delaware, Connecticut, Louisiana, New York, Mississippi, Oregon, and Vermont do not.

Qualified Medicare Beneficiary or QMB

The QMB program assists beneficiaries in paying Medicare Part A and Part B monthly payments, coinsurance, and deductibles. As a general rule, the income limit is set at 100% of the Federal Poverty Level (FPL)—plus a $20 allowance. This means that a single candidate can earn up to $1,093 per month, and a married couple can earn up to $1,472 per month. The asset thresholds are higher than those for full Medicaid coverage. A single applicant’s limit is $7,970, and a married couple’s limit is near $11,960.

Specified Low-Income Medicare Beneficiary or SLMB

The SLMB program assists applicants in the payment of Medicare Part B premiums. Typically, the income limit is 120 percent of the FPL, plus an additional $20 that is overlooked. A single person can make up to $1,308 per month, and a married couple can earn up to $1,762. An individual’s asset limit is $7,970, and a married couple’s asset limit is $11,960.

Qualifying Individual or QI

The QI program, also known as Qualified Individual, helps pay the monthly Medicare Part B premium. The income limit is 135% of the FPL, plus a $20 deduction. This means that a single applicant can earn up to $1,469 per month, and married couples can make up to $1,980 per month. An individual’s assets are restricted to $7,970, while a couple’s assets are limited to $11,960.

Obtaining Medicaid Eligibility

Please keep in mind that exceeding the Medicaid limits in one’s state does not result in automatic disqualification. This is due to the existence of Medicaid-compliant planning strategies designed to reduce one’s countable income and assets to meet the standard limits. 

A word of caution: Assets should not be given away for at least five years (2.5 years in California) before the date of the Medicaid application. (New York is currently implementing a 2.5-year look-back period for long-term home and area-based services.) This is because of Medicaid’s look-back period, during which past transfers are reviewed to ensure that an applicant (or an applicant’s spouse) has not gifted or sold assets for less than fair market value. If this rule is broken, it is assumed that the assets were transferred to meet Medicaid’s asset limit, and a period of Medicaid disqualification will be calculated as a penalty. 

How to Apply

Contact your local Social Security Administration office to get a Medicare plan. If you are new to health insurance coverage, you can apply through our site NewMedicare.com. 

To apply for Medicaid, contact the insurance agency in your state. Learn about the Medicaid application process for long-term care. You may want to take a non-binding Medicaid eligibility test before purchasing Medicaid coverage. The results of which will assist families in determining whether a loved one is eligible for Medicaid or if they need to collaborate with a Medicaid planning specialist to become eligible.  

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