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Medicaid & Medicare Advantage

Medicaid is a state administered health care program for low-income individuals. Medicare is the health care insurance program offered by the U.S. government and available to the elderly and disabled. One way to receive either benefit is through private health plans, better known as Medicare Advantage plans. Some Medicare beneficiaries also qualify for Medicaid, and these individuals can have both Medicare Advantage and Medicaid at once.

  1. Medicaid Eligibility

    • Eligibility varies from state to state. Those who are disabled and elderly are in a protected class that must be covered by each Medicaid program. Medicaid eligibility is based on strict income and asset limits which are determined by the federal poverty guidelines.

    Medicare Advantage Eligibility

    • There are four population classes that are eligible to enroll in Medicare Advantage: individuals 65 and older, those diagnosed with end-stage renal disease, the disabled and those diagnosed with amyotrophic lateral sclerosis. Medicare recipients are eligible to switch to Medicare Advantage whenever they are in an enrollment period.

    Coverage

    • Both Medicaid and Medicare Advantage are comprehensive health care programs. There are a few differences in services covered, and most of these differences will vary from plan to plan and from state to state.

      Medicaid must offer the elderly and disabled full dental coverage, including preventive screenings and cleanings. Medicare Advantage plans do not have to offer dental unless it is medically necessary; however, several plans do. Availability of these plans varies depending on the coverage area. Another difference is that several Medicaid programs cover some classes of drugs that Medicare is excluded from covering by law. These drugs include barbiturates, benzodiazipines, drugs for weight loss and over-the-counter drugs. Medicaid drug coverage varies by state.

    Coordination

    • Those covered by both Medicare (either traditional or Medicare Advantage) and Medicaid are known in the industry as "dual eligibles." When a dual eligible goes to receive a medical service, the provider should bill the Medicare Advantage plan first; in other words, Medicare Advantage is the primary insurance. Medicaid acts as a supplemental insurance by filling in some of the gaps left over such as co-payments and deductibles. Medicaid will also be billed for any services Medicare Advantage does not cover.

    Extra Help

    • Dual eligibles in every state are automatically enrolled in a federal assistance program called Extra Help, which is administered by the Social Security Administration and helps pay for most of the costs left over from the Medicare Part D prescription drug benefit. Most Medicare Advantage plans include Part D as a part of the health care package. Extra Help will still work with Medicare Advantage plans, and beneficiaries will pay no premium or deductible and very low co-payments at only $1.10 for generics and $3.30 for brand-name drugs. However, these co-payments will most likely be covered by Medicaid's drug benefit.

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