Jeffrey Wade
Medicaid is a federal-state program that provides health coverage for low-income individuals, families, children, pregnant women, the elderly, and people with disabilities. Each state has its own eligibility requirements, and individuals must meet specific income and resource criteria to qualify. If you have other insurance, such as Medicare, and also qualify for Medicaid, understanding how these two programs work together is essential. In such cases, each type of coverage is called a payer, with one designated as the primary payer and the other as the secondary payer. The primary payer covers expenses up to its limits and then sends the remaining balance to the secondary payer. This coordination of benefits ensures that individuals with multiple coverages can maximize their healthcare benefits and minimize out-of-pocket expenses.
| Characteristics | Values |
|---|---|
| What is Medicaid? | A joint federal and state program that helps cover medical costs for certain low-income people, families and children, pregnant women, the elderly, and people with disabilities. |
| Who is eligible for Medicaid? | Eligibility depends on the state. In general, it depends on income, resources, and residency. |
| How does Medicaid work with other insurance? | If you have Medicare and other health insurance, each type of coverage is called a "payer." The "primary payer" pays up to the limits of its coverage, then sends the rest of the balance to the "secondary payer." |
| What are the benefits of Medicaid? | Medicaid offers benefits not normally covered by Medicare, like nursing home care, personal care services, and non-emergency medical transportation. |
| What is the impact of Medicaid? | A large body of research shows that Medicaid beneficiaries have better access to care than uninsured people and are less likely to postpone or go without needed care due to cost. |
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What You'll Learn
Medicaid eligibility
Medicaid is a joint federal and state program that, together with the Children's Health Insurance Program (CHIP), provides health coverage to over 77.9 million Americans. Medicaid is the single largest source of health coverage in the United States. It provides free or low-cost medical benefits to eligible individuals with low incomes, including children, pregnant women, parents, seniors, and individuals with disabilities.
To participate in Medicaid, federal law requires states to cover certain groups of individuals. Low-income families, qualified pregnant women and children, and individuals receiving Supplemental Security Income (SSI) are examples of mandatory eligibility groups. States have additional options for coverage and may choose to cover other groups, such as individuals receiving home and community-based services, and children in foster care who are not otherwise eligible.
The Affordable Care Act of 2010 created the opportunity for states to expand Medicaid to cover nearly all low-income Americans under 65. Eligibility for children was extended to at least 133% of the federal poverty level (FPL) in every state, and states were given the option to extend eligibility to adults with incomes at or below 133% of the FPL. Most states have chosen to expand coverage to adults, and those that have not yet expanded may do so at any time.
The Affordable Care Act established a new methodology for determining income eligibility for Medicaid, which is based on Modified Adjusted Gross Income (MAGI). MAGI is used to determine financial eligibility for Medicaid, CHIP, and premium tax credits and cost-sharing reductions available through the health insurance marketplace. MAGI-based eligibility does not allow for income disregards that vary by state or eligibility group, and it does not allow for an asset or resource test. Some individuals are exempt from the MAGI-based income counting rules, including those whose eligibility is based on blindness, disability, or age (65 and older).
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Medicare and Medicaid coordination of benefits
If you have Medicare and other health insurance, each type of coverage is called a "payer". The "primary payer" pays up to the limits of its coverage and then sends the remaining balance to the "secondary payer". If the "secondary payer" does not cover the remaining balance, you may be responsible for the remaining costs. This order of payment is called "coordination of benefits".
Coordination of Benefits (COB) refers to the activities involved in determining Medicaid benefits when an enrollee has coverage through an individual, entity, insurance, or program that is liable to pay for health care services. For example, if you have Medicare and qualify for full Medicaid coverage, your state will pay your Medicare Part B (Medical Insurance) monthly premiums. Depending on the level of Medicaid you qualify for, your state might also pay for your share of Medicare costs, like deductibles, coinsurance, and copayments.
Individuals eligible for Medicaid assign their rights to third-party payments to the State Medicaid Agency. States are required to take all reasonable measures to ascertain the legal liability of third parties to pay for care and services that are available under the Medicaid state plan. Third-party resources must meet their legal obligation to pay claims before the Medicaid program pays for the care of an individual eligible for Medicaid.
The Benefits Coordination & Recovery Center (BCRC) consolidates the activities that support the collection, management, and reporting of data. It also has a agreement with private insurance companies for the automatic crossover of claims.
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Medicaid and other insurance payers
Medicaid is a federal-state program that helps cover medical costs for certain low-income people, including families and children, pregnant women, the elderly, and people with disabilities. Each state has its own eligibility requirements, and in general, eligibility depends on income level and residency in the state.
Medicaid interacts with other payers when beneficiaries have other sources that are legally liable for payment of their medical costs. These sources may include private insurance, Medicare, other public programs such as the Ryan White program, workers' compensation, and amounts received for injuries in liability cases. In these cases, each type of coverage is called a "payer", with the "primary payer" covering costs up to the limits of its coverage and then sending the remaining balance to the "secondary payer". If the secondary payer does not cover the remaining balance, the individual may be responsible for the remaining costs.
Medicaid may also pay for services that would typically be financed by other public agencies or programs, either because they are designated as payers of last resort after Medicaid or are not considered legally liable third parties. In addition, there are circumstances in which state Medicaid programs arrange for another entity to pay providers for Medicaid-covered services, such as through managed care contracts or premium assistance programs.
Medicaid offers benefits not typically covered by Medicare, such as nursing home care, personal care services, and non-emergency medical transportation. When Medicaid benefits supplement another coverage source, such as Medicare or private insurance, it is often referred to as wrap-around coverage.
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Medicaid and Medicare drug plans
Medicaid and Medicare can work together to provide health coverage. Medicaid is a federal and state program that helps cover medical costs for certain low-income people, including families and children, pregnant women, the elderly, and people with disabilities. Each state has its own eligibility requirements, and you must be a resident of the state where you are applying for benefits.
Medicare is a federal program that provides health insurance for people aged 65 and over, as well as some younger people with disabilities. It is made up of several parts, including Part A (Hospital Insurance) and Part B (Medical Insurance). If you have both Medicare and Medicaid, you are considered "dually eligible". In this case, Medicare pays first for Medicare-covered services, and Medicaid pays secondary, covering any remaining costs that Medicare doesn't pay for.
Medicare drug coverage, also known as Medicare Part D, helps pay for prescription drugs. If you are dually eligible, Medicare will automatically cover your prescription drug costs instead of Medicaid. However, Medicaid may still pay for other drugs and services that Medicare doesn't cover.
If you have Medicare and other health insurance, such as a group health plan, retiree coverage, or Medicaid, each type of coverage is called a "payer". The "primary payer" pays up to the limits of its coverage and then sends the remaining balance to the "secondary payer". If there is still an unpaid balance after the secondary payer, you may be responsible for the remaining costs. This order of payment is called "coordination of benefits".
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Medicaid and Medicare coverage options
Medicaid and Medicare are both health insurance programs, but their coverage options differ. Medicaid is a joint federal and state program that helps cover medical costs for certain low-income people, including families, children, pregnant women, the elderly, and people with disabilities. Each state has its own eligibility requirements, and applicants must be residents of the state they are applying in.
Medicaid provides free or low-cost medical benefits, including nursing home care and personal care services, which are not typically covered by Medicare. If an individual has both Medicare and qualifies for full Medicaid coverage, they are considered "'dually eligible". In this case, Medicare pays first for Medicare-covered services, and Medicaid pays last for any remaining balance.
Medicare, on the other hand, has different parts that cover specific services. Part A covers inpatient hospital care, skilled nursing facility care, hospice care, and home health care. Medicare Part B covers medical insurance, and individuals may need to sign up for this before receiving coverage from a secondary payer. Part C, or Medicare Advantage, offers an alternative way to receive your Medicare benefits, often including prescription drug coverage (Part D). Part D helps cover the cost of prescription drugs, including certain shots or vaccines.
If an individual has Medicare and other insurance, including Medicaid, each type of coverage is called a "payer". The "primary payer" pays up to its coverage limit, then sends the remaining balance to the "secondary payer". If there is still an unpaid balance, the individual may be responsible for the remaining costs.
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Frequently asked questions
Medicaid is a joint federal and state program that helps cover medical costs for certain low-income people, families and children, pregnant women, the elderly, and people with disabilities.
Each state has its own eligibility requirements. In general, eligibility depends on at least one or a combination of factors, including income, resources, and residency.
You can apply for Medicaid by creating an account with the Health Insurance Marketplace and filling out an application. If it looks like you qualify, your information will be sent to your state agency, which will contact you about enrollment.
If you have Medicare and other health insurance, including Medicaid, each type of coverage is called a "payer". The "primary payer" pays up to the limits of its coverage, then sends the rest of the balance to the "secondary payer". If you are dually eligible for Medicare and Medicaid, Medicare pays first.
