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How Medicaid supports 1 in 5 Medicare enrollees
In 2016, an estimated 11.7 million Medicare beneficiaries – about 20 percent of all enrollees – were also enrolled in Medicaid and are known as dual-eligible beneficiaries or dual-eligibles. And while you might not hear that term often – or at all – it's worth your time to understand what it means to have both Medicare and Medicaid (especially if you or a loved one is part of the "Medicare-Medicaid" population).
How does a doctor’s participation in Medicare affect reimbursement?
Medicare reimbursement refers to the payments that hospitals and physicians receive in return for services rendered to Medicare beneficiaries. The reimbursement rates for these services are set by Medicare, and are typically less than the amount billed or the amount that a private insurance company would pay.
Four ways to adjust your Medicare coverage
If you're like most Medicare enrollees, you probably aren't planning to make any changes to your existing coverage for the coming year, but – like most beneficiaries – you should probably at least consider it during Medicare's open enrollment period. And if you have Medicare Advantage, you also have an opportunity to change your coverage between January and March each year.
Important Medicare enrollment dates
Enrollment dates for Medicare are critical. Missing an enrollment date could cost you higher premiums down the line — or it could cost you coverage entirely.
Q: What’s the difference between Medicare and Medicaid?
A: Medicare and Medicaid are two important U.S. healthcare programs. Each program serves different groups of people, although some people are enrolled in both programs.
Medicare is a federal government-sponsored healthcare program for those 65 and over, and for younger people who are disabled (Medicare covers 64 million Americans; more than 8.1 million of them were under age 65 as of late 2021). Most people with Medicare paid FICA taxes during their working years, and realize the benefits of that tax through Medicare coverage. The federal government establishes the eligibility criteria for Medicare.
Medicaid, on the other hand, is a healthcare program for low-income individuals who could not otherwise afford health insurance. Nearly 77 million Americans were enrolled in Medicaid as of mid-2021, plus another 7 million enrolled in CHIP.
Medicaid is jointly funded by the federal government and the state in which an enrollee lives. States establish their own eligibility standards and services for Medicaid, within general parameters set by the federal government. Before the Affordable Care Act (ACA), most states only provided Medicaid coverage to people who were low-income and also either disabled, elderly, pregnant, children, or the caretaker of a minor child. These populations had to be covered according to federal law.
The ACA included a provision to expand Medicaid eligibility to more adults in every state as of January 1, 2014, but a Supreme Court ruling in 2012 made Medicaid expansion optional. As of 2022, there are still 12 states that have not expanded Medicaid. In the District of Columbia and the 38 states where Medicaid has been expanded, coverage is available for anyone with an income up to 138% of the poverty level (in the continental U.S., that amounts to about $18,754 in annual income for a single adult in 2022).
Here’s more information on Medicaid in each state, and where the states are in terms of Medicaid expansion under the ACA.
Original Medicare coverage is the same in every state, including eligibility, benefits, and premiums. A Medicare beneficiary pays the same price for Medicare Part B, regardless of where the beneficiary lives (although premiums for Part B do vary based on other factors).
But a significant portion of Medicare’s coverage is provided through private plans. The private plan options under Medicare — including Medicare Part D (prescription coverage), Medigap (supplemental coverage), and Medicare Advantage — vary considerably from one area to another in terms of which insurers offer coverage, the specific plan designs they offer, and the pricing. Most of the general regulations that apply to those plans are the same in every state. State regulations for Medigap plans do vary considerably, however. Federal rules do not require Medigap insurers to offer coverage to disabled enrollees under age 65, but the majority of the states have implemented their own rules to ensure at least some access to Medigap plans for these enrollees. You can click on a state on this map to see applicable Medigap rules.
Most states use private insurers to administer at least some Medicaid benefits. 39 states and D.C. covered at least some Medicaid beneficiaries through Managed Care Organizations (MCOs) as of mid 2019, but even more states use some form of managed care. If your state requires you to receive Medicaid benefits through an MCO, you have 90 days during which you can choose among the different plans available, but a plan will be chosen for you if you don’t select one. This is called the “choice period,” and once it ends, you usually have to remain in your plan for 12 months.
Many states require adults to enroll in an MCO to receive Medicaid benefits as long as they’re not also eligible for Medicare. But if you have Medicare and Medicaid, then your Medicaid benefits are usually delivered through your state’s fee-for-service program. (This is because Medicaid is mostly only paying for your Medicare cost-sharing and premiums at this point.) Some states use private insurers to deliver specific types of Medicaid benefits – like long-term care – while providing other Medicaid benefits using fee-for-service. (22 states did this as of August 2017, covering nearly 1.8 million beneficiaries.)
As of 2019, 12.3 million people were covered under both Medicare and Medicaid (amounting to about 20% of Medicare beneficiaries). This happens when a person has Medicare because they are elderly or disabled and also qualifies for Medicaid due to their financial situation. Dual eligibles have low incomes and often have chronic medical needs (60 percent of dual eligibles had multiple chronic conditions in 2018.) To improve their access to health care, the ACA created the Medicare-Medicaid Coordination Office (MMCO) to help align coverage under the two programs. The law also allowed insurers to offer specialized plans that include both Medicare and Medicaid benefits.
Despite efforts to align coverage, the most popular type of managed care plan for dual eligibles is actually a type of Medicare Advantage plan called a dual-eligible special needs plan (D-SNP). As of 2021, about 3 million people were enrolled in hundreds of D-SNPs operating in 43 states.
Previous federal legislation required D-SNPs to contract with state Medicaid programs so that enrollees’ deductibles and cost-sharing were properly billed to Medicaid (the D-SNP would pay the charges covered by Medicare). All D-SNPs must have contracts with state Medicaid agencies. And states can also require D-SNPs to pay for these things themselves and be reimbursed by the state, reducing the likelihood of dual-eligible enrollees improperly being billed. And as of 2021, D-SNPs are required to integrate care with Medicaid programs in additional ways.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.