When it comes to billing, understanding the difference between primary and secondary insurance is vital.
More than 70 million Americans rely on Medicaid for health insurance, but it is often not the only insurance they have. Many are what is known as dual eligible – qualifying for both Medicare and Medicaid. This page explores how Medicaid coordinates with other types of insurance.
Can you have Medicaid and other insurance?
Yes, you can have Medicaid and other insurance. In addition to Medicare-Medicaid dual eligibility, you can also have Medicaid and a private insurance plan.
Whether you have Medicare or health insurance through a private insurer, your Medicaid coverage will be supplemental. That means that, if you have commercial or employer-based insurance, Medicaid is the "payer of last resort" and will be the last to contribute to any medical bills, coinsurance, or copayments.
All other sources of coverage have to pay claims before Medicaid will cover any costs under federal law. This is known as third-party liability, or TPL, and means that the responsibility for primary payment is on any available third-party resources and not Medicaid. Coverage that has to pay before Medicaid includes:
- Court-ordered health coverage
- Group health plans
- Long-term care insurance
- Managed care organizations
- Pharmacy benefit managers
- Self-insured plans
- Settlements from a liability insurer
- State and federal health insurance programs (not excluded by law)
To see exactly how your Medicaid program will coordinate with any other coverage, contact your state Medicaid program.
So, how do you bill Medicaid?
Short answer: You don't bill Medicaid. The way coordination of benefits works when you have dual coverage is that your healthcare provider first sends the bill to Medicare. Once Medicare pays its share, the bill then goes to your secondary insurer of record, in this case Medicaid. Medicaid will pay its share and then, if there's anything still remaining, you would be billed for the rest.
What is dual eligibility?
As stated above, you can qualify for both Medicaid and Medicare, which is known as dual eligibility. The big difference between the two is that Medicaid eligibility is income-based, whereas Medicare is age-based.
Original Medicare is composed of two parts. Part A covers your inpatient care, and Part B covers outpatient care. Prescription drug coverage comes through a Medicare Part D plan and is not included in Original Medicare.
You can also obtain your Original Medicare coverage through a Medicare Advantage plan (Part C), most of which include prescription drug coverage. Advantage plans are sold through private insurers, so cost and coverage options vary.
Dual eligible Medicare plans
Some Part C plans are known as Dual-eligible Special Needs Plans (D-SNPs) and are made specifically for people who have both Medicare and Medicaid.
If you qualify for both Medicare and Medicaid, you likely won't have to pay anything out of pocket as most of your healthcare costs will be covered. You also automatically qualify for Extra Help, a program that helps people pay their Part D prescription drug costs.
Dual eligibility requirements differ depending on your state, so the best way to find out if you qualify is to contact your state Medicaid program. And if you'd like to learn more about your D-SNP plan options, call us toll-free at 888-992-0738. One of our licensed agents will answer your questions and explain your Medicare options.
What are Medicare Savings Programs?
Often, beneficiaries that are dual eligible are automatically enrolled in a Medicare Savings Program. There are four different savings programs that help people pay for associated Medicare costs. All income and resource limits listed below are slightly higher in Alaska and Hawaii.
Qualified Medicare Beneficiary (QMB) Program
If you qualify for the QMB program, you get Extra Help, so you pay no more than $4.30 for any medications covered by your drug plan. You may get a bill for a small Medicaid copayment, if one applies, but Medicare providers cannot bill you for any items or services Medicare covers. Income and resource limits are as follows:
- Monthly income limit of $1,235 and a resource limit of $9,090 for individuals
- Monthly income limit of $1,663 and a resource limit of $13,630 for married couples
Specified Low-Income Medicare Beneficiary (SLMB) Program
Qualifying for the SLMB program also means you get Extra Help and pay no more than $10.35 for any medications covered by your drug plan. The SLMB program pays for your Part B premiums, and you must have Part A and Part B to qualify. Income and resource limits are as follows:
- Monthly income limit of $1,478 and a resource limit of $9,090 for individuals
- Monthly income limit of $1,992 and a resource limit of $13,630 for married couples
Qualifying Individual (QI) Program
The QI Program covers your Part B premiums, and you must apply every year to stay in the program. States approve applications on a first-come, first-serve basis, with priority going to those that had the program the previous year. You get Extra Help if you qualify for the QI Program, so you pay no more than $10.35 for any medications covered by your drug plan. Income and resource limits are as follows:
- Monthly income limit of $1,660 and a resource limit of $9,090 for individuals
- Monthly income limit of $2,239 and a resource limit of $13,630 for married couples
If you qualify for Medicaid, you cannot be on the QI Program, but should qualify for one of the other savings programs.
Qualified Disabled Working Individual (QDWI) Program
The QDWI Program pays for your Part A premiums. You qualify if you have a disability, are working, and lost your Social Security disability benefits and premium-free Part A because you returned to work. Income and resource limits are as follows:
- Monthly income limit of $4,945 and a resource limit of $4,000 for individuals
- Monthly income limit of $6,659 and a resource limit of $6,000 for married couples
Having Medicaid and Medicare
Remember, you do not lose Medicaid eligibility just because you qualify for Medicare. Some states may require you to enroll in a Medicaid private health plan or Medicaid Managed Care (MMC) plan. Through these, you often have the option to enroll in a Medicare Advantage plan as stated above. These plans are designed to help coordinate benefits and care between Medicaid and Medicare.
Medicaid also provides some health benefits that Medicare does not, so while Medicare covers most of your health care needs, Medicaid may provide:
- Dental care
- Nursing home care
- Physical therapy
You can learn more about how Medicaid and Medicare work together here. But it's important to remember that, even if you have Medicaid, Medicare is always the primary payer. Failure to sign up for Medicare when you're eligible could leave you owing lifelong late enrollment penalties.