Since my son is disabled, he used to receive SSI. He is on Medicaid. Now he is getting SS benefits due to his father retiring and getting on SS. He got a letter today saying it’s time to choose Medicare coverage. But if he’s on Medicaid, he can’t be on Medicare, also, can he?
This situation is called dual eligibility.
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Thanks. I guess I don’t see the point in having a dual plan, since Medicaid (MaineCare) pays for everything. The $28,000+ injection he gets every 6 months has a co-pay of $3. He has been hospitalized for months in the past and had expensive procedures, and has never had to pay anything out-of-pocket.
Maybe it hasn’t been a problem for you, but in some parts of the country, it can be difficult to find providers for those with Medicaid-only coverage. Dual-eligibles get more robust reimbursement.
Additionally, there have been some excellent pilot programs in a number of states that seek to provide integrated care for the dual-eligible population, rolling in supports that aren’t normally covered by either insurance alone. This article doesn’t give the most elegantly-written explanation, but it links to a lot of sources: https://www.healthaffairs.org/content/forefront/expanding-home-and-community-based-services-dually-eligible-adults-behavioral-health
Bottom line, he still won’t pay anything out of pocket with Medi-Medi, and the providers will get paid better, and he may get some benefits he doesn’t get now, depending on what Maine does with duals.
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Thanks, I will look into it. I guess we’ve been fortunate to be in Maine - my son has had everything covered, including a weekly support person. I’m sure his care has run well over $1M by this point.
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There’s a lot more people than one might realize who are eligible for both Medicare and Medicaid. When someone is enrolled in both, the Medicare insurance coverage is primary and Medicaid is secondary.
So how it would work when you go to the doctor is you’d have to give them both insurance policy numbers. Every provider will ask you for “COB” information (coordination of benefits), which basically means that they’re asking if you have more than 1 insurance plan for medical coverage. If you’re enrolled in both Medicare and Medicaid, then the answer to that type of question would be yes. 
Sometimes based on which state you live in, what Medicare will pay/cover can be slightly different than what Medicaid will pay for/cover. The payment of the claim is all handled by the insurance companies.
Depending on the laws in different states, you can choose to be enrolled by the same insurance company for both your Medicare and Medicaid plans. Or you can be enrolled with a Medicare plan with one company but be enrolled in Medicaid with a different company.
Sometimes, insurance companies where you can enroll in both the Medicare and Medicaid coverage at the same company will have special ‘dual-eligible’ member programs for care management, coordination of care, and other programs for dual-eligible members with specific categories of health conditions.
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I’ve called several different places, and every person tells me another place to call. I will call the state Medicaid office tomorrow.
I just keep thinking, “If it’s not broke, don’t fix it.” We’ve never had any issues with Medicaid. But I guess it could change in the future.
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This. 100%. My DH just recently became eligible for Medicare so I am new to all of this, but until and unless someone can show you, in writing, why/how there could be any advantage to having the policy which now covers everything as the secondary insurance, I would be very hesitant to change anything.
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Have you called SHIP? That seems to be the most authoritative source of info about all things Medicare/MaineCare, for Maine residents. SHIP & Medicare Assistance | Department of Health and Human Services I have no experience with SHIP but I’ve heard the MA equivalent, which is called SHINE, is helpful, so hopefully SHIP is too.
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Thank you, that looks great!
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I agree and would also ask for information in writing that having dual Medicaid/Medicare coverage would be superior to what you currently have. It sounds like he currently has excellent coverage and I would be VERY reluctant to do anything to jeopardize that.
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My disabled loved one has Medicare A&B plus is covered as disabled dependent under our family plan. We would be very reluctant to do anything to upset the current coverage because it meets her needs pretty well.
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Back in the day, I had seen some patients who had Medicare primary and Medicaid secondary. You might want to check to see which one would be primary and secondary for you and if it would make a difference.
Currently, if someone is dual-enrolled, Medicare is always primary.
That’s the way it was for all of the folks who had both. My point was to make sure @MaineLonghorn considered this.
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In Massachusetts we go to hospital financial counseling offices for info and sign up. Here, SHINE counseling is for Medicare and can be accessed at the hospital offices, town halls and senior centers. Not sure what the similar resources are in Maine.
Medicaid can result in possible clawback after death. Not true with Medicare. As far as I know. Not sure if this is relevant for your son. The clawback tends to be for long term care.
Medicaid clawback refers to the process by which states recover funds spent on Medicaid services from the estates of deceased beneficiaries, primarily through the Medicaid Estate Recovery Program (MERP).
What is Medicaid Clawback?
Maine was one of the states that enacted a law eliminating clawback, at least if you have your money in an ABLE account as my son does.
" Maine has a law that prevents the state from seeking Medicaid payback from a deceased ABLE account holder’s account, so the funds are generally not subject to Medicaid clawback. This means after qualified disability expenses and funeral costs are paid, the remaining balance can go to a successor beneficiary or the estate, according to state law and ABLE program rules."
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Passing this on to a friend whose sister is in a similar situation to your son’s, and is moving to Maine where my friend lives. Sister is in a nursing home.
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I believe that the difference is that providers (doctors, hospitals) are reimbursed more since Medicare is primary and has higher reimbursement rates than Medicaid.
In my state, there are certain things which Medicaid will pay for but Medicare will not. Also, in a situation in which (for example) the claim comes in from the provider for $100…and Medicare will pay 80% of that (so Medicare pays the provider $80). Then Medicaid will pay whatever the state Medicaid-contracted rate is for that service to fill in the gap for the remaining $20.
Usually, of course, the $$ amount that the provider submits in the bill is more than that, but Medicare reduces it (like any medical insurance does) to the negotiated rate and then Medicaid kicks in for the remaining amount left over.
Another example:
Provider submits bill for $200 for something.
Medicare says, “no, we’re not paying you $200 for that. Our contracted rate w/you for that CPT code is to pay 80% of $100 for it. So we’re paying you $80.”
Provider submits secondary claim to patient’s Medicaid insurance.
Medicaid pays the gap (so the $20).