Medicare Advantage with Medicaid

Medicare Advantage with Medicaid

Someone with Medicare and Medicaid is called a “Dual eligible”.  So someone with Medicare Advantage with Medicaid is a “dual” enrolled in Medicaid and a Medicare Advantage plan.  A full dual can enroll in a standard MAPD or a Dual Advantage plan

How advantage plans work with Medicaid and Medicare Savings Program

Someone with Medicaid can enroll in a standard Medicare Advantage plan.   Medicaid will pay the copays and cost shares associated with the plan.  Everyone with Medicaid also has “extra help” which will help with the cost share of the rx plan in the Advantage plan.   Medicaid acts as the payor of last resort with an advantage plan.  As a result, it is important to check that doctors are in network in the advantage plan and that drugs are in the formulary.   If the doctor is out of network, Medicaid will not help with the cost.  Same goes for prescriptions.  Extra help will not help with the cost of drugs out of the plans formulary

Medicare Advantage with Medicaid -Dual Eligible MAPD plans (Also called Dual SNP plans)

Dual plans are Medicare Advantage plans with rx coverage that are specifically created for those on Medicaid and QMB (more on Medicaid and Medicare Savings Program levels below)   Dual plans often have additional benefits such as dental, vision, transportation, Flex cards, OTC benefits and PERS.   Dual plans have no cost share in network.  Only those with Medicaid or at the QMB level of LIS qualify for dual plans.

Medicaid and QMB levels

Full Medicaid (Somtimes called QMB+) provides the highest amount of coverage for members.  It will cover the cost shares for Original Medicare and copays and cost shares of advantage plans.  Those of full Medicaid also have access to dental, vision and transportation benefits. In most states there are income and asset limits in order to receive Medicaid benefits.  Medicaid will coordinate with a standard MAPD, Dual MAPD or PDP plan.

Medicare Advantage with Medicaid:  Medicare Savings Programs (MSP)

Those that do not qualify for Medicaid/QMB+ may be eligible for MSP.   MSP has 4 levels in most states.  In most states qualifying for MSP is based on income and assets. In some states it is based on income only  The levels are:

• QMB
• SLMB
• QI
• ALMB  (Many states do not have the ALMB level)
  • QMB will provided similar benefits to Medicaid.  It will cover medical costs and copays and help with Rx costs secondary to Original Medicare or Medicare Advantage.  QMB does not provide additional benefits such as dental, vision and transportation.
  • SLMB and QI will help with Rx costs only
  • ALMB will help with Rx costs only

Medicare Advantage with Medicaid: Part B premiums and Rx premiums

Those with Medicaid and MSP do not pay for their Medicare part B premium.  They will not pay their drug plan premiums up to the state benchmark premium.  Part B and Part D late enrollment penalties are also waived for those with Medicaid or MSP.

Special Enrollment Period (SEP)

Anyone with Medicaid or MSP will have a special election to make plan changes once a quarter for the first 3 quarters.  They also get a special election when first getting Medicaid or MSP or when losing either help program.

Learn about quoting, comparing and enrolling members in dual plans with Sunfire

Crowe and Associates Free Medicare Lead Program