Medicare and Medicaid Dual Eligibles
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Are you eligible for both Medicare and Medicaid and turning age 65?
DUAL ELIGIBLES are people who are eligible for both the Medicare health plan and Medicaid limited income health plan.
Like over 12 million Americans who are turning 65 and becoming Medicare eligible for the health plan, but if also enrolled or becoming eligible for Medi-caid you are in luck.
There’s great news! You don’t have to choose between one health plan or the other.
You can utilize BOTH the robust health plans Medicare offers (Original Medicare or Medicare Advantage) as well as the Medicaid assistance plan health insurance offered for people with lower incomes.
What are the basics?
Let’s get right to the basics. Here’s a quick breakdown of covered topics:
WHAT IS A MEDICARE MEDICAID DUAL ELIGIBLE?
WHO QUALIFIES?
FULL AND PARTIAL MEDICAID ELIGIBILITY
WHAT EXTRA BENEFITS CAN YOU RECEIVE?
WHAT DOCTORS CAN YOU VISIT?
WHY IS HAVING BOTH MEDICARE AND MEDICAID IMPORTANT IF YOU QUALIFY?
HOW CAN YOU FIND OUT IF YOU QUALIFY?
WHAT IS A MEDICARE MEDICAID DUAL ELIGIBLE?
What exactly does ‘Dual Eligible’ for Medicare and Medicaid mean in practical terms to the average person?
A Medicare Dual Eligible is a person who is eligible to enroll in the health plan coverage for Medicare and the limited income health insurance program Medicaid.
A second level of qualification which also works for Medicaid is called Special Needs which refers to specific health conditions
If you’re turning 65 or enrolled in Medicare but not sure if you may qualify for income based Medicaid in California the basic standard is income lower than 138% of the federal poverty level.
Medicare is typically the primary payor and will pay first on your medical claims. Medicaid pays second towards remaining costs for medical expenses that Medicaid covers.
It’s really as strong of a medical coverage scenario as you’re going to find these days.
WHO QUALIFIES?
Here’s a table which is really helpful in reflecting the federal poverty level and qualifying program based on your household size, income, and assets for California residents:
Is your income is on the borderline? Are there different tiers or levels for benefits of Dual Eligibility, or Medicaid assistance?
Yes! There are several different levels of eligibility with Medicaid mostly depending on your income type or if you have special needs medical issues.
Next, you must live in a service area where there is a Medicare Advantage plan with a Dual Eligibility plan offer.
But, at the simplest perspective if you understand there are two main categories: people who qualify as 1) fully eligible for Medicaid who get maximum benefits and 2) people who are ‘partial eligible’ who get less benefits, such as no premium assistance or less medical expense cost coverage.
Partial Medi-Caid eligibles in California
An individual might be a ‘partial eligible’ for Medicaid, for example, if their income surpasses the State of CA Medicaid qualification of 138%, but is beneath the federal poverty level to qualify for full eligibility at 200% of the federal poverty level.
Partial Medicaid/Medicare Dual Eligibles primarily get their premiums paid for Part A & Part B, but don’t receive assistance with their medical expenses via Medicaid.
Ask us if you would like us to check for you to see if you qualify for full or partial medi-caid assistance.
Full Medi-Caid eligibles in California
People who meet both the State and Federal income requirements for Medicaid qualify for Full Medicaid health benefits, which includes the following:
-Premiums paid for Medicare Part A Hospital, B Physicians Services, C Medicare Advantage, & D Prescription Drugs
-Medical Expenses under those Medicare Parts A Hospital, Medicare Part B Physicians Services, & Part D Prescription Drugs plans such as down to zero out of pocket depending on the DSNIP plan you choose.
DNSIP stands for Dual Eligible Special Needs Plans for Medicare and Medicaid recipients.
The Special Needs members are those who qualify based on certain medical conditions. The broad categories are:
Respiratory Disease
Cardiovascular Disease
Diabetes
Cancers
Note: There are many sub categories and qualifiers within these categories in obtaining Chronic Conditions Medicare.
Contact Us for more information and to get your questions answered.
Or, to check plan availability and rates in your area instant quotes are available here.
What Extra Benefits Can You Receive?
Many insurance carriers will provide you with additional benefits added to the plans not included in Original Medicare.
The first benefit is lower cost!! We’ve got your attention now.
Medicare Dual Special Needs plans are Medicare Advantage plans where typically zero or low premium is offered, and dramatically increased coverage is available for medical expenses out of pocket.
Special Needs Plans Coordination
On a Special Needs Plans Many times the insurance carrier will assign a specific contact person to assist in the management of the member= EXTREMELY HELPFUL in today’s complex healthcare landscape.
This contact is useful in coordinating the proper medical care program for healthcare management necessary to treat the Chronic Condition.
A specialized provider network is typically leveraged by this plan for the condition
Added plan benefits can be added for additional treatment beyond Original Medicare
Extra Benefits
Many insurance carriers will provide you with additional benefits added to the plans not included in Original Medicare.
The first benefit is lower cost!! We’ve got your attention now.
Medicare Dual Special Needs plans are Medicare Advantage plans where typically zero or low premium is offered, and dramatically increased coverage is available for medical expenses out of pocket.
Special Needs Plans Coordination
On a Special Needs Plans Many times the insurance carrier will assign a specific contact person to assist in the management of the member= EXTREMELY HELPFUL in today’s complex healthcare landscape.
This contact is useful in coordinating the proper medical care program for healthcare management necessary to treat the Chronic Condition.
A specialized provider network is typically leveraged by this plan for the condition
Added plan benefits can be added for additional treatment beyond Original Medicare
- In addition California G Supplement Inspire members will also get:
Dual Eligible Additional Coverage
Wait, there’s more?
Yes, the insurance carriers have the ability to add additional benefits to the Dual Medicare Medicaid DSNP plans!
Dental Coverage: when available usually matches a typical stand alone individual HMO dental plan
Fitness Programs: often come in the form of gym memberships & online programs
Fitness Plan: some carriers offer a session with a personal trainer to design a customized fitness plan
Long Term Care: on an individual basis
Over the Counter Medications: Plans with this benefit will allow qualifying over the counter medications via plan allowance.
Allowance and Cash Back Programs
Been a long time since you’ve gotten an allowance?
Many insurance carriers offer cashback dollars to spend on medical expenses, but even non medical costs such as over the counter items, groceries, transportation including Uber, Lyft and taxi rides.
A debit card is issued so the transactions are simple and convenient. Many insurance carriers even have rollover programs if some of the funds go unused.
Contact Us to find out more about potential allowance and cashback plans available in your area.
What Doctors Can You Visit?
What good is the plan if you can’t see your doctor?
Like Obama said in 2014 “If you like your doctor, you can keep your doctor.” Wait, that’s another subject..
Simply put, to utilize the plan you must visit a doctor who accepts and is a contracted provider for the plan you are enrolled in.
To maximize your coverage to the fullest extent possible you need to visit both a provider contracted on your Medicare Advantage Dual Needs plan and a doctor who accepts Medicaid.
We will be happy to help you check your desired doctors, hospitals, and medical groups across all the plans available in your area to find you a plan which fits your needs!
Contact Us today to talk with a licensed agent!
In California depending on the level of MediCal you are eligible for your MediCal insurance carrier may automatically be the same insurance carrier as your Dual Special Needs Medicare Advantage plan.
Same carrier for both Medicare & Medicaid. Simplifies things.
Why is having both Medicare and Medi-Caid Important if you Qualify
Inflation is hitting. You still read the ‘papers’.
We’re going to need to buckle up and save on all the costs we can especially as you retire. This includes the medical expense category which is statistically going to dramatically rise as you age.
If you do qualify for both programs the ability to bill Medicaid as a secondary payor can be really beneficial cost wise.
For example, if you happen to have a large medical bill such as a hospital stay or major surgery, on most Medicare Advantage plans you will have cost sharing. This is either the percentage of the bill you pay (usually between 10-40%) or the co-pay which is the flat dollar amount.
Here’s the key:
If the expense is covered by Medicaid as well, your Medicaid health plan will kick in and pay as a secondary payor after your Medicare Advantage carrier pays on the claim.
Medicare Advantage plans frequently have out of pocket cost sharing on medical bills, just like your health plan so this can be a huge help.
This assumes all providers are contracted on the plans of course.
Check your rates and benefits today.
How To Find Out If You Qualify
The easiest way to get started is to Contact Us now and get started with a licensed agent.
In the meantime here’s some great online resources where you can find info on applying for MediCal and Medicare/Social Security.
Local County Social Security Offices
You can apply at your local county Social Security office. A directory can be found here:
https://www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx
Covered California
If your income is below the 138% of the Federal Poverty Level we can submit an application via Covered California application system Once submitted successfully with any required information CoveredCA then notifies your local county Social Services office. It takes typically at least 30 days until a review is begun.
Paper Application
Finally, you can download and print a paper application to mail in via U.S. Postal Servic0
Where Is The G Inspire Medicare Supplement Available?
If you live in Southern California and don’t see the plan available in quoting engines online, that’s because it’s not available in your area.
G Inspire Medicare Supplement is available only in these California counties currently:
Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado, Fresno, Glenn, Humboldt, Kings, Lake, Lassen, Madera, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Placer, Plumas, Sacramento, San Benito, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tuolumne, Yolo, and Yuba respectively.
Silver Sneakers is no cost when purchased with a Blue Shield of California Medicare Supplement or Medicare Advantage plan.
What If I’m Enrolled In Another Medicare Supplement Already?
No problem whatsoever! You can apply any month of the year and may be approved with simple medical underwriting. Or, if you have health conditions California offers the Birthday Rule where a current Original Medicare + Supplement enrollee can switch to the same plan level or below without any medical underwriting.
CONTACT US if you’d like submit an application emailed, mail, phone, or online.
For a a brochure of the G Inspire Medicare Supplement additional coverage details download G Inspire.
Is there any else missing? Yes, and thanks for asking. G Inspire includes FREE Teledoc Physician consultation by Phone or Video. Yes, FREE.
Why is this a good thing. For one, there’s no waiting in emergency rooms or Physician Office check in rooms full of sick people.
That way if you’re really sick and can’t afford to get sicker, or healthy and don’t want to get sick you can stay home safely during your Teledoc visit, all at no charge.
Better service, more convenient, less costly.