| Thu, Oct 17, 2013 @ 09:00 AM

Are You Dual Eligible or Qualify for a Medicare Special Needs Plan?

Posted by Medicare Made Clear

medicaid eligibilityDo you have Medicare Parts A and B and have either a chronic disease or a low income? You may qualify for dual eligibility or a Medicare Special Needs Plan (SNP).

Find out the differences between dual eligibility and Medicare Special Needs Plans and who may be eligible for each one.

Dual eligibility – A person is considered “dual eligible” when they qualify for both Medicare and Medicaid coverage. Nine million low-income elderly and disabled people are covered under both the Medicare and Medicaid programs.1 These beneficiaries are more likely than other Medicare beneficiaries to be frail and have more than one medicaid.

Dual eligible’s main source of health insurance comes from Medicare. Medicare pays for most medical services, including inpatient and outpatient care, doctor services, diagnostic and preventative care and outpatient prescription drugs under Part D plans.

Medicaid fills in the gaps and pays for services not covered by Medicare, such as dental and long-term care. Medicaid may also help pay Medicare’s premiums and out-of-pocket expenses. Together, these two programs may help to protect very low-income Medicare beneficiaries from possible unaffordable out-of-pocket medical and long-term care costs.2

Who’s eligible: Certain people who are age 65 or older or are under age 65 with a permanent disability receiving Social Security Disability Insurance or have end-stage renal disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).3 Visit Healthcare.gov for other eligibility requirements and to find out if you may qualify for Medicaid.

Medicare Special Needs Plans – Medicare Special Needs Plans (SNPs) are a type of Medicare Advantage Plan (like an HMO or PPO). Medicare SNPs are available only to people with certain diseases and circumstances.

Medicare SNPs are approved by Medicare and run by private companies. When you join a Medicare SNP, you get your Medicare Part A and Part B and prescription drug coverage through the plan. However, you’re still in the Medicare program and have the same Medicare rights and protections as anyone else in the program.

Just like with other Medicare health plans, you will have to see providers who belong to the plan, or use certain hospitals to get covered services. In most cases, you will need referrals to see specialists. The Medicare SNP will still cover emergency or urgent care, even if you’re out of the plan’s service area.

Who’s eligible: You may be eligible to join a Medicare SNP if you have Medicare Parts A & B, live in the plan’s service area, and meet at least one of the plan’s other eligibility requirements, such as:

  • You have one or more of the following severe or disabling chronic conditions, including:
    • alcohol and other drug dependence, cancer, heart disease, dementia, diabetes mellitus, end-stage liver disease, HIV/AIDS, stroke, lung disease, disabling mental health conditions, and more.
  • You live in an institution (like a nursing home), or you need nursing care at home.
  • You have both Medicare and Medicaid.  

Different types of Medicare SNPs may be available in different parts of the country. Look at the “Medicare & You” handbook mailed to you each fall for the Medicare SNPs in your area.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.


Your Guide to Medicare Special Needs Plans: Medicare.gov

Medicare’s Role for Dual Eligible Beneficiaries: The Henry J. Kaiser Family Foundation

What’s the Difference Between Medicare and Medicaid?: Medicaremadeclear.com

1,2,3 The Henry J. Kaiser Family Foundation: Medicare’s Role for Dual Eligible Beneficiaries, 2012


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