QUESTION: Does my mother still need Medicare if she is approved for Medicaid?

Medicaid is an entitlement program that helps to pay medical bills, skilled nursing care, Medicare Part B premiums, and many other benefits. To receive Medicaid you must complete an application and submit financial documents to your County Department of Social Services office (DSS).

Medicare is Health Insurance provided by the Federal Government and administered by the Centers for Medicare & Medicaid Services (CMS). Most individuals receive Medicare benefits when they turn 65 years of age. Some individuals receive Medicare due to a Disability when they are younger than 65.

Your mother has Medicare and probably some other insurance products to go with it. That could be a Medicare Advantage Plan (including Prescription Drug Coverage) or a Medicare Supplement Plan (Medigap) + a Prescription Drug Plan. When she applied for Medicaid, she was approved because she has a medical need for care or is in a skilled nursing facility and has met the income & asset requirements.

Using this scenario, her Medicare coverage, either type, will be her Primary Insurance and the Medicaid coverage will be secondary coverage. Medicaid is always the “payer of last resort”. This phrase means all other means of paying for care through health insurance, or automobile insurance, etc. is used first. The remainder of the bill is then submitted to Medicaid for payment.

There are actually multiple levels of Medicaid eligibility. Each level of eligibility has slightly different criteria and ways of handling medical bills. Based on the information you provided, I am assuming she is ‘Fully Medicaid Eligible’. In this situation, if your mother has a Medicare Advantage Plan, she would continue to use the network of providers her plan allows. When she sees those providers the co-pays she used to pay would be submitted to Medicaid for payment. Your mother would not pay those co-pays.

If your mother has Medicare + Medicare Supplement Plan + Prescription Drug Coverage. Her medical bills would be submitted to her two levels of coverage and if there were co-insurance costs, she paid in the past, those cost would be submitted to Medicaid for payment. Your mother would not pay those co-pays. For her medications, it would continue to go through her Prescription Drug Plan and the co-pays would be significantly reduced or eliminated with her Medicaid eligibility. This Program is call Low-Income Subsidy (LIS) or Extra Help.

With the addition of Medicaid to her situation, your mother could elect to eliminate her Medicare Supplement Plan. If she chose to do this, she would “suspend” her Medicare Supplement Plan. This suspension would allow her to re-enroll into a Medicare Supplement Plan at a later date if her Medicaid eligibility ever changed. Your mother needs to keep her Prescription Drug Coverage.

If your mother has a Medicare Advantage Plan and Medicaid, she could choose to dis-enroll from the Medicare Advantage Plan. She would go back to Original Medicare and would be required to add a Prescription Drug Plan to cover her medications.

If your mother ever lost her Medicaid eligibility, she would have a Special Enrollment Period (SEP) to use to enroll in a health insurance product including Prescription Drug coverage of her choice. She would have 60 days to make that change of coverage.

With Medicaid eligibility, your mother also has a different SEP to change her insurance at different times throughout the year based on her medication needs.

Your question was does my mother still need her health insurance? Yes she definitely needs her Medicare Part A & B. She definitely needs Prescription Drug Coverage. She has many Medicare approved options to get that Prescription Drug Coverage. She can also make different decisions than she has up to this point to control her costs, related to premiums and health care. It is important that she realize she must continue to use providers that take both her Medicare Health Insurance and her New York State Medicaid.

Senior Life Matters is a community based program sponsored by Lutheran Jamestown. For questions and concerns or to reach Janell Sluga, GCMC, call us at 716-720-9797 or e-mail at SLM@lutheran-jamestown.org.