Medicare, Medicaid and Dual Eligibility

Medicare and Medicaid are often mistaken to be the same thing. While they are both government programs that help pay for healthcare coverage, they are quite different.

Medicare is a federal health insurance program for people that are 65 years old and older. If you haven’t paid into Social Security long enough, you will have to pay premiums for Medicare Part A. Premiums for Medicare Part B and Medicare Part D are decided based on the beneficiary’s income. People with End-Stage Renal Disease and specific disabilities are eligible to enroll in Medicare before turning 65.

Medicaid is a healthcare program that assists low-income individuals or families to pay for long-term medical and custodial care costs. Medicaid is not solely funded at the federal level. States provide up to half of the funding for the Medicaid program. In some states, counties also contribute funds. Medicaid is a social welfare or social protection program rather than a social insurance program like Medicare.

If you are qualified for both Medicaid and Medicare, you’re considered “dual-eligible” and you may qualify for benefits through Medicare Savings Programs (MSP). MSPs are state-run and will provide coverage for certain Medicare premiums, copayments, and deductibles. There are more than 9 million people that qualify for dual eligibility in the United States. There are four dual eligible beneficiary plans:

  • Qualified Medicare Beneficiary (QMB) Program – Helps pay for Medicare Part A and Medicare Part B premiums, deductible, coinsurance, and copayments.
  • Specified Low-Income Medicare Beneficiary (SLMB) Program – Helps pay your Part B premium.
  • Qualifying Individual (QI) Program – Helps pay your Part B premiums.
  • Qualified Disabled Working Individual (QDWI) Program – Pays for Part A premium for certain people who are disabled and working.

One of the biggest differences between Medicare and Medicaid services is reimbursement. Medicare reimbursement refers to payments hospitals and doctors receive as a result of services provided to patients that are covered under Medicare. The reimbursement goes to the billing provider. Doctors can choose to accept the rate that Medicare has set for the services they have provided. Medicare pays 80% of these costs.

Medicaid reimbursement is similar to Medicare reimbursement in that the payment goes to the provider. However, doctors who chose to be Medicaid providers are required to accept the reimbursement provided by Medicaid as payment in full for the services provided.

Medicaid benefits help pay for Medicare costs of a dual eligible plan. Plus, dual eligible plans often cover benefits not offered by Medicare, including routine hearing, vision and dental benefits, as well as providing coverage for transportation. If you think you qualify for Medicaid, call your state medical-assistance office.



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