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

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Differentiating Medicare and Medicaid

People frequently mix up the phrases Medicaid and Medicare. It is crucial to distinguish between them because of this. Medicare is a free government health insurance program for seniors and people with disabilities. Medicaid is a joint federal and state medical assistance program for people of any age who are in financial need.

Both programs give a range of advantages, such as hospital stays and doctor visits, but only Medicaid offers long-term nursing home care. In order to minimize and delay nursing home admissions, Medicaid also pays for long-term care and services in home and community-based settings, such as adult foster care homes and assisted living facilities. Long-term home and community-based benefits are not offered by Medicare, but certain Medicare Advantage plans (Medicare Part C) started to offer them in 2019.

Both the Medicare and Medicaid programs are managed by the Centers for Medicare and Medicaid Services (CMS). CMS collaborates with state agencies to manage the Medicaid program in each state. The Social Security Administration (SSA) is the organization that people apply to for the Medicare program.

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Definition: Dual Eligible

“Dual eligibles” or occasionally “Medicare-Medicaid enrollees” are people who qualify for both Medicare and Medicaid. People must be enrolled in Medicare Part A (hospital insurance) and/or Medicare Part B in order to be considered dual eligible (medical insurance). People may choose Medicare Part C instead of Original Medicare (Part A and Part B) (Medicare Advantage). While Medicare Advantage plans are administered by Medicare-approved private insurance companies, Original Medicare is managed by the federal government. Participants in the program receive Medicare Part A, Part B, and frequently Part D through Medicare Advantage (prescription drug coverage).

People must also be enrolled in either full coverage Medicaid or one of Medicaid’s Medicare Savings Programs in order to be dual eligible. In-patient and out-patient hospital care, laboratory testing, and x-rays are all covered by full coverage Medicaid. Medicaid also covers limited in-home personal care assistance and nursing facility care. While many states provide these supports through 1915(c) Medicaid waivers, some states provide long-term care and support in the home and community through their state Medicaid programs. Although MSPs don’t offer the same coverage, they do help with the cost of Medicare premiums. They might also pay for Medicare’s co-pays and deductibles.

Benefits of Dual Eligibility

People who are covered by both Medicaid and Medicare may have more comprehensive medical coverage and pay less out of pocket. Medicare is always the first payer for expenses that are covered by the program, such as medical and hospitalization costs. Given that Medicaid covers these costs, Medicaid (the secondary payer) will pick up the slack if Medicare is unable to pay the full amount. Medicaid also pays for some costs that Medicare does not, such as long-term skilled nursing home care and assistance with personal care in the community and at home. (Medicare only covers 100 days of nursing home care.) One Medicare Advantage plan does, as was already mentioned, cover the cost of some long-term care services and supports. Medicare premiums, deductibles, and co-payments are partially covered by Medicaid through Medicare Savings Programs.

Long-Term Care Benefits

A wide range of long-term care benefits and supports are offered by Medicaid to enable people to age at home or in their community. These benefits are not offered by Original Medicare, but some Medicare Advantage plans do provide a range of long-term home and community-based services. The following list of potential long-term care benefits is not all-inclusive, and not all benefits may be accessible in every state.

  • Adult Day Care / Adult Day Health
  • Personal Care Assistance (at home, adult foster care homes, and assisted living facilities)
  • Medical / Non-Medical Transportation
  • Respite Care (to give the primary caregiver a break)
  • Congregate Meals / Meal Delivery
  • Home Health Aide / Skilled Nursing
  • Home Modifications (widening of doorways, installation of ramps, the addition of pedestal sinks to allow wheelchair access, etc.)
  • Personal Emergency Response Systems
  • Housekeeping / Chore Services
  • Companion Services
  • Transition Services (from a nursing home back to home)
  • Therapies (physical, occupational, and speech)
  • Medication Administration

Durable medical equipment, such as wheelchairs and walkers, will be covered by both Medicaid and Medicare.

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Eligibility Requirements

Medicare

Medicare is a federal program, thus eligibility rules are the same in every state. Prior to applying for Medicare, a person must be a citizen of the United States or a resident who has been legally residing in the country for at least five years. Additionally, a person needs to be at least 65 years old, incapacitated, have end-stage renal illness, or have Lou Gehrig’s disease (amyotrophic lateral sclerosis). Medicare eligibility is not determined by a person’s wealth; there are no restrictions on income or assets.

Medicare Part A normally does not require a monthly premium from recipients (hospitalization insurance). A person (or their spouse) must have worked for at least 10 years and paid into Medicare in order to qualify for premium-free coverage. The total cost of the monthly premium in 2022 is $499. The monthly cost of Medicare Part A for people who have worked but have not yet fulfilled the complete work requirements is $274. The $1,566 yearly Part A hospitalization deductible applies. One is required to cover a cost share (coinsurance) for services after the deductible is satisfied.

A $170.10 monthly premium is required of enrollees for Medicare Part B (medical insurance). Additionally, there is a $233 deductible every year.

Medicare Parts A and B enrollment is required in order to sign up for a Medicare Advantage (MA) plan. Depending on the plan, the monthly fee varies, but it often costs $20 or less. Although not all MA plans to impose a monthly premium, when one does, it is in addition to, if applicable, the monthly Part A and Part B payments.

Medical and functional standards must be satisfied in order to be eligible for long-term home and community-based services offered by Medicare Advantage plans as an additional benefit.

Medicaid

Medicaid eligibility requirements are more complicated than Medicare eligibility requirements. This is because, within limits established by the federal government, each state sets its own requirements. There are numerous routes to Medicaid eligibility, and each route has its own requirements, even within the same state.

Medicaid has asset and income restrictions. In general, the individual Medicaid income and asset limits for institutional Medicaid (nursing home Medicaid) and Home and Community Based Services (HCBS) through a Medicaid Waiver are $2,523 per month and $2,000, respectively, in 2022. State-by-state differences exist in the income and asset thresholds. View state-specific Medicaid eligibility requirements. Additionally, candidates must demonstrate a functional need for care, which is typically equivalent to a level of care comparable to that offered in a nursing home. Study more.

Medicare Savings Programs

Medicare Savings Program income and asset restrictions do not take into account the aforementioned financial standards. Three MSP programs are pertinent to senior citizens. The majority of states in 2022 adhere to the restrictions below, although some states have their own rules. For instance, the income limits are higher in Alaska, Connecticut, the District of Columbia (DC), Indiana, Maine, Massachusetts, and Hawaii, and there is no asset limit in Alabama, Arizona, Connecticut, Delaware, DC, Louisiana, Mississippi, New York, Oregon, and Vermont.

Qualified Medicare Beneficiary (QMB)
The QMB program assists in covering Medicare Part A and Part B monthly premiums as well as cost-sharing, coinsurance, and deductibles. The upper-income limit is equal to the FPL plus a $20 exception, or 100% of the FPL. The maximum monthly income for a single applicant is $1,153, and the maximum monthly income for a couple is $1,546. In comparison to full Medicaid, the asset limits are higher. The maximum is $8,400 for a single applicant and $12,600 for a couple.

Specified Low Income Medicare Beneficiary (SLMB)
The SLMB program assists with paying the Medicare Part B premium. The upper-income limit is set at 120% of the federal poverty level, plus $20. The maximum monthly income for an individual is $1,379, and the maximum for a couple is $1,851. The maximum asset amount is $12,600 for a couple and $8,400 for an individual.

Qualifying Individual (QI)
The Qualified Individual program, also known as QI, assists with paying the Medicare Part B monthly premium. The upper-income limit is 135% of the federal poverty level plus $20. A single applicant’s income is limited to $1,549 per month, while a couple’s is limited to $2,080 per month. The maximum amount of assets for an individual is $8,400 and for a couple, it is $12,600.

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Becoming Medicaid Eligible

Over the Medicaid cap(es) in one’s state, income and assets are not automatically disqualifying. This is due to the existence of Medicaid-compliant planning techniques designed to reduce one’s countable income and/or assets in order to comply with the limit (s).

A word of caution: Prior to the date that a person applies for long-term care Medicaid, there is a look-back period. During this time, previous asset transactions are examined to make sure that neither the applicant nor the applicant’s spouse gifted or sold any assets for less than their fair market value. In the event that this regulation has been broken, it is presumed that the assets were transferred in order to fulfill Medicaid’s asset limit, and a period of Medicaid disqualification as a result of the violation will be determined. California is an outlier, as it has a 2.5-year look-back period, which is more liberal. Another example is New York, where long-term home and community-based services are currently not subject to a look-back period. But no earlier than March 31, 2024, the state will establish a 2.5-year look-back period.

 

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