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Revision 18-1; Effective March 1, 2018
Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. For persons who are eligible for full Medicaid coverage, Medicare health coverage is supplemented by services that are available under the Medicaid program, according to eligibility category. For persons enrolled in both programs, any services that are covered by Medicare are paid for by the Medicare program before any payments are made by the Medicaid program, since Medicaid is always the "payer of last resort." Certain other Medicare beneficiaries may receive help with Medicare premium and cost-sharing payments through the Medicaid program.
A-9100 Medicare Benefits
Revision 18-1; Effective March 1, 2018
Medicare is a federal program under Title XVIII of the Social Security Act and is administered by the Social Security Administration (SSA). Medicare provides health care benefits for individuals age 65 or older, under age 65 with certain disabilities, and any age with permanent kidney failure (called end-stage renal disease).
Those younger than 65 will receive Medicare after getting Social Security disability benefits for at least two years.
There are exceptions to the two-year waiting period, including:
- a chronic renal disease that requires a kidney transplant or maintenance dialysis (SSA determines if an individual with a chronic renal disease diagnosis meets the requirements for the exception to the waiting period); or
- Lou Gehrig's disease (amyotrophic lateral sclerosis).
Medicare is available to an individual who has paid into the Medicare trust account through payroll taxes sometimes called the Federal Income Contributions Act (FICA). Most employers are required to withhold FICA taxes, but there are some exceptions. Federal government employees have been eligible to participate in Social Security only since 1984. As a result, some older employees have opted to remain with the former Civil Service Retirement System. Some state and local government employee retirement plans also are not covered by Social Security.
If an individual receives Medicare, they are either:
- 65 years old or older; or
- determined disabled by SSA.
Medicare is divided into four parts:
- Medicare Part A (Hospital Insurance) – Helps pay for inpatient care in a hospital, skilled nursing facility or hospice, and for home health care if certain conditions are met. Most people do not have to pay a monthly premium for Medicare Part A because they or a spouse paid Medicare taxes while working in the U.S. If the Part A premium is not automatically free, an individual still may be able to enroll and pay a premium.
- Medicare Part B (Medical Insurance) – Helps pay for medically necessary doctors’ services and other outpatient care. It also pays for some preventive services (like flu shots), and some services that keep certain illnesses from getting worse. Most individuals pay the standard monthly Medicare Part B premium.
- Medicare Part C (Medicare Advantage Plans) – Individuals must be enrolled in both Part A and Part B. These plans are available through Medicare-approved private insurance companies. The plans cover all of the Part A and Part B services and, in most cases, include Part D Prescription Drug Coverage as well. Some plans offer additional services, such as vision, hearing, dental, and health and wellness programs. Individuals pay a monthly premium and co-payments that are usually lower than the coinsurance and deductibles under the original Medicare. Actual costs and benefits vary by plan.
- Medicare Part D (Medicare Prescription Drug Coverage) provides prescription drug coverage. Individuals can add Part D by joining a Medicare Prescription Drug Plan (PDP). Individuals must pay a deductible and usually pay coinsurance each time services are received. The PDPs are available through private insurance companies approved by Medicare. Costs and benefits vary by plan.
In most cases, the Part B and Part D premiums are deducted from the Social Security or Railroad Retirement check. The recipient is responsible for calendar-year deductibles and co-pay liabilities for both Parts A and B.
The Part C premium is handled by the private company that offers the benefit as a Medicare Advantage Plan. The Medicare Advantage Plan has its own benefits and coverage that differs from the traditional Medicare benefits. Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans. These companies must follow rules set by Medicare. However, each Medicare Advantage Plan can charge different out-of-pocket costs and have different rules for how one gets services.
Extra help for Part D (Medicare Prescription Drug Coverage) is available for people with Medicare who have limited income and resources. If eligible for extra help, Medicare will pay for almost all prescription drug costs. Extra help provides a subsidy based on the amount of income and resources an individual has.
Full Subsidy Benefits from Extra Help:
- Full premium assistance up to the premium subsidy amount
- Nominal cost sharing up to out-of-pocket threshold
- No coverage gap
Other Low Income Subsidy Benefits from Extra Help:
- Sliding scale premium assistance
- Reduced deductible
- Reduced coinsurance
- No coverage gap
Individuals who have Medicare and Medicaid or who are eligible for the Medicare Savings Program (MSP) do not need to apply for extra help through the SSA.
Individuals can apply for extra help or get more information about extra help subsidy by calling Social Security at 800-772-1213 (TTY 800-325-0778) or visiting www.socialsecurity.gov.
A-9200 Medicare Buy-In
Revision 11-4; Effective December 1, 2011
To ensure that Medicaid recipients who are entitled to Medicare receive maximum health care protection, the state pays for certain recipients' Medicare Part B premiums. This process is called buy-in. For those persons who have dual entitlement, Medicare becomes the payer of first resort, with Medicaid paying deductibles and co-insurance for Medicaid-covered services.
A-9210 Eligibility Requirements for Medicare Buy-In
Revision 11-4; Effective December 1, 2011
Recipients are eligible for buy-in if they are:
- 65 or older and U.S. citizens;
- 65 or older and lawfully admitted aliens who have lived in the U.S. five consecutive years;
- under 65 and have received or been eligible to receive Social Security or Railroad Retirement disability benefits for 24 consecutive months; or
- under 65 and qualify for Medicare Part A because of chronic renal disease.
A-9220 Time Frames for Medicare Buy-In Enrollment
Revision 13-4; Effective December 1, 2013
Persons who have Medicare Part B coverage at the time they are certified for Medicaid are enrolled as follows:
- SSI and Temporary Assistance for Needy Families (TANF) recipients are enrolled for buy-in effective the first month they receive a cash payment.
- ME-Pickle recipients who are RSDI pass-on recipients are enrolled in continuous buy-in.
Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-Pickle in February and was certified eligible on March 5. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient's RSDI check.
- ME-Disabled Adult Child (DAC) recipients who are RSDI pass-on recipients are enrolled in continuous buy-in.
Example: The recipient was denied SSI on Dec. 31 due to a cost of living increase. The recipient applied for ME-DAC in March and was certified eligible on April 10. Medical effective date is Jan. 1. Medicare Part B buy-in is effective Jan. 1. The recipient will be reimbursed by SSA for any premiums withheld from the recipient’s RSDI check.
- ME-Nursing Facility, ME-State School, ME-Waivers, ME-Non-State Group Home and ME-State Group Home recipients who are QMB-eligible, whose certification was accomplished as a program transfer, and whose certification has no break in Medicaid coverage are eligible for continuous buy-in.
Example: The MQMB recipient has SSI and RSDI income and enters a nursing facility in January. SSI is denied effective Feb. 28. The recipient qualifies for QMB and Medicaid. The medical effective date for MQMB is March 1. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.
- Recipients who are denied in error and are recertified have continuous enrollment for buy-in. This is true except for those recipients in ME-Nursing Facility who are not eligible for QMB benefits.
Example: The MQMB recipient is enrolled in Medicaid, ME-Nursing Facility. During the first year's review process, the recipient was denied due to excess resources effective Jan. 31. During a subsequent application in March, the eligibility specialist discovers the recipient should not have been denied in January and grants a medical effective date of Feb. 1, reopening the case. The recipient is entitled to continued Medicare buy-in and is reimbursed for any premium withheld from the RSDI check.
- ME-Nursing Facility recipients who are also QMB-eligible are enrolled for buy-in effective the month of their eligibility for QMB benefits.
Example: The recipient is certified for ME-Nursing Facility and is also eligible for MQMB. Certification is Jan. 15, and the MQMB effective date is Feb. 1. Medicare buy-in is effective Feb. 1. The recipient will be reimbursed by SSA for any premiums withheld after the effective date of buy-in.
- Recipients eligible for QMB who do not have Medicare Part B coverage at the time of Medicaid certification are enrolled in buy-in when they meet Medicare criteria. These recipients remain on the buy-in rolls while they are eligible for Medicare, Medicaid and QMB benefits.
When a recipient is enrolled in buy-in, SSA stops charging for Part B premiums. Usually this occurs the month after SSA has acknowledged receiving the recipient's name as an addition to the buy-in rolls. If premiums have been withheld from the monthly benefit, the recipient's check should reflect an upward adjustment by the third month after the month of certification.
Address questions about the buy-in status of a recipient who has been certified for at least three months to: