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Medicaid is a health insurance program for people with low income who meet certain eligibility requirements. Programs can vary from state-to-state. Medicare is a federal health insurance program for people who are age 65 or older, disabled persons, or those with end-stage kidney disease. Medicare eligibility is not based on income, and basic coverage is the same in each state.

When you apply for Medicaid, you must fill out an application form. You will also need to have various documents:

  • Information about household members (name, date of birth and Social Security number)
  • Rent or mortgage information
  • Expenses (utilities, daycare, etc.)
  • Vehicle information
  • Bank statements
  • Income (pay stubs)
  • Proof of disability or medical records showing a lasting medical condition
  • Recent medical bills
  • Proof of citizenship
  • Additional information as requested

The Explanation of Benefits is a document you will get each month you use your prescription drug coverage. It will tell you the total amount you have spent on your prescription drugs and the total amount we have paid for your prescription drugs. You will get your Explanation of Benefits in the mail each month that you use the benefits that we provide.

What Does Dual Eligible Mean?
Plans often called “dual” or “dual eligible” are designed for people who qualify for both Medicare and Medicaid at the same time. These plans include all Medicare Part A (hospital stay) and B (doctor visit) benefits and Part D prescription drug coverage. For people with limited incomes, these plans may offer better health care coverage than Original Medicare and a separate Part D plan.

Who is it for?
Dual eligible plans are most common for seniors and certain disabled individuals with low incomes.

How do I qualify?
To qualify, you must receive Medicare (Parts A & B) and full Medicaid benefits where Medicaid pay for all or part of your Medicare copayments, coinsurance and deductibles. To know if you qualify, you should look at the letter you received from your State Medicaid office, or call them to find out your status.

How does it work?
The Medicaid benefits can help in several ways from paying for Medicare costs and covering benefits not offered by Medicare, such as hearing, transportation, vision, dental and long-term care.

The type of Medicaid benefits you receive are determined by your state and may vary based upon your income and resources. Some dual eligibles receive assistance from Medicaid so they do not have to pay the Medicare cost share. These dual eligibles are known as Qualified Medicare Beneficiaries (QMB). If you are not a QMB, you are responsible for the full plan cost share listed in the Summary of Benefits.

Cost share is the amount of payment that a member, or for certain dual eligibles, the State Medicaid Agency, is responsible to pay for doctor visits or other covered services. Cost share can be either a copay or coinsurance. A copay is the preset, flat amount you pay for a service, like $10 for a visit to the doctor.

Coinsurance is what you pay for services after any plan deductibles. It is a percentage of the cost of the service you have received, like 20% of the cost of your hospital visit. Coinsurance varies by plan and by benefit.

Dual eligibles who receive assistance under Medicaid for cost share payments should have their Part D premium fully covered (if applicable) by the Medicare Low Income Subsidy (LIS). You should receive a letter from the Centers for Medicare and Medicaid Services (CMS) or the Social Security Administration (SSA) if you qualify for extra help with your prescription drug costs. Remember, you are still responsible for small Part D copayments. If your plan has a Part C health plan premium, you will be responsible for the full amount.

Should there ever be a change in your Medicaid status, and you no longer qualify for an LIS, you will receive a bill for your Part D premium (if applicable). In addition, a loss of Medicaid will also affect your cost share for covered services. While you have Medicaid, and for the two additional months after your loss of Medicaid, you can switch to another Medicare Advantage plan.

Medicare provides coverage for hospital stays (Part A), doctors bills (Part B) and prescription drugs (Part D). Benefits under Medicaid vary by state. In many states, Medicaid covers services that Medicare does not cover. Examples of services that may be covered by a state Medicaid program include personal and homemaker care or dental services. Eligibility for Medicaid benefits are determined by your state.

To learn about the benefits that may be available to you under your state Medicaid program, your best source of information is your State Medicaid Agency.

UnitedHealthcare health plans are offered by United Healthcare Insurance Company, who contracts directly with the Federal government and several state governments to provide health care services to both Medicare and Medicaid recipients in their communities. In most cases, we are able to provide our members more benefits and coverage than Medicaid and Medicare alone.

The Medicaid benefits held by dual eligible people can help in several ways from paying for Medicare premiums and cost-sharing, to coverage of benefits not offered under Medicare, such as hearing, transportation, vision, dental and long-term care.

These plans have benefits designed for people living independently in their own home. They may cover you if you have to go to a nursing home to recover from an illness. Benefits and services may be in addition to what you get from your Medicaid program. They do not change what you already get from your Medicaid program.