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Whether you are new to Medicare or have had it for years, one question tends to come up: What is the difference between Medicare and Medicaid? Although both programs are administered by the government, they are vastly different programs, and it is important to know the differences between the two.

Let’s start with a quick recap of Medicare to lay the groundwork. Medicare is a federally funded program in the United States offering health coverage to those 65 years an older, People under age 65 with End Stage Renal Disease and ALS, and those under the age of 65 with disabilities after collecting social security disability income for 24 months.

Original Medicare is composed of Part A (Hospital) insurance and Part B (Medical) insurance. Many Medicare beneficiaries choose to enroll into additional coverage under Medicare Supplement Plans, Medicare Part D Prescriptions Drug Plans, or Medicare Part C Medicare Advantage Plans.

Medicaid on the other hand is a joint state and federally funded program that provides health coverage to those qualifying as low income. As the state maintains these programs, eligibility depends on the state in which an individual resides. The state determines scope of services and service payment rates.

Beneficiaries who qualify for both Medicare and Medicaid are what is considered “Dually Eligible”. This includes those enrolled in Medicare Parts A and/or B and receiving either partial or full levels of Medicaid benefits or assistance with cost sharing or with Medicare premiums.

Here is a breakdown of the different levels:

  • Qualified Medicare Beneficiary (QMB) Program: Helps pay premiums, deductibles, coinsurance, and copayments for Part A, Part B, or both programs
  • Qualified Medicare Beneficiary Plus (QMB+) Program: Helps pay premiums, deductibles, coinsurance, and copayments for Part A, Part B, or both programs PLUS entitlement to the full range of Medicaid benefits.
  • Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums only
  • Specified Low-Income Medicare Beneficiary (SLMB+) Program: Helps pay Part B premiums and entitlement to the full range of Medicaid benefits.
  • Qualifying Individual (QI) Program:Helps pay Part B premiums only
  • Qualified Disabled Working Individual (QDWI) Program: Pays the Part A premium for certain disabled and working beneficiaries who have disabilities

Does Medicaid or Medicare pay first?

Medicare pays first, and Medicaid pays second. However, Medicaid may help pay for services that Medicare does not cover such as personal or nursing home care.

Special Enrollment Periods (SEP)

You can make changes to your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, like if you qualify for or lose Medicaid edibility. In addition, if you are eligible for both Medicare and Medicaid, you can join, switch, or drop your Medicare Advantage plan or Prescription Drug plan one time per quarter in the first 9 months of each calendar year—January to March, April to June, and July – September. If you make a change during these periods, it will take effect on the first day of the following month. Any changes made between October 15 and December 7 (Annual Enrollment Period) will take effect on January 1.

How do I apply for Medicaid?

As mentioned, each state has different requirements when applying for Medicaid. Find more information on your states Medicaid website.

For those in Washington State you can contact your local DSHS office or visit the DSHS website online:

VibrantUSA is here to help!

Our local VibrantUSA agents can help you navigate plan options for dual-eligible individuals. Our services are always free, and we are available for year-round customer service support.

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