While both of these programs provide medical coverage, their functions and operations are very different. Here we will break down what each of them are, how you qualify for each, and how they work together.
What are they?
A federal healthcare program funded by taxpayer contributions and premiums paid by those enrolled.
Available to the elderly, disabled, and those with certain serious illnesses.
Has a monthly cost that varies based on income level.
Apply through the Social Security Administration.
Covers medical only
A federal and state ran health insurance program funded by tax payer dollars.
Enrollment is based on income level and disability.
Has no monthly cost, but may have extremely low copays or out of pocket costs for some services.
Covers medical and can cover medications
Apply through Healthcare.gov or state Medicaid website
Quick note: Medicare is largely for those over age 65, while Medicaid is for those with low income. Many reading this probably live in California, and most Californians will know Medicaid as Medi-Cal. Medicaid is largely ran by the state, hence the state-branded name. Each state will have their own variant of this for their own state.
What if I have both?
If you are over 65 and have low income, then it is very likely that you will have both Medicare and Medicaid (often classified as a “Medi-Medi” for short or formally as a full dual-eligible). If this is the case, you will need to know how they coordinate with each other.
The first thing to know is that Medicare will be your primary and Medicaid will be your secondary coverage. This means that your Medicare will be the first to pay for any covered service and then Medicaid will step in to pay all or a portion of any copays or deductibles that are left over by Medicare (as long as Medicaid also covers that benefit). This will be important when you need something covered but only one insurance covers it. This shows up most often with things like incontinence supplies.
Medicare does not cover incontinence products, but Medicaid does. Therefore, to get coverage the medical equipment company will need to get a denial letter from Medicare first before they request to have Medicaid pay for it. Knowing this can help you plan for the time it takes to go through the denial process. Even if you happen to have both Medicare and Medicaid, there are still plenty of services not covered by either insurance.
These services include glasses (unless after cataract surgery, and even then only for one pair), over-the-counter supplies, erectile disfunction medications, personal emergency response button (commonly known as the “Help I’ve Fallen and I Can’t Get Up” button), fitness benefits, and more. To get coverage for these services, you have the option to be enrolled in a Medicare Advantage plan (Part C). The good news is that these plans will likely be available at no additional cost for any dual-eligible individual, and most counties have a few “Medi-Medi”options to choose from. For more information on Medicare and Medicaid as well as Medicare Advantage plans tailored for dual-eligible individuals, contact us 1-877-651-7526 TTY: 711 to meet with a licensed professional that is eager to support you.