Medicare offers medical coverage and benefits to individuals aged 65 or older or those who meet specific disability criteria. Oregon Health Plan (OHP) is a program that helps people with low income and resources pay for medical expenses. It is run by both the federal and state governments. Additionally, OHp provides benefits that are typically not included in Medicare.
Understanding your healthcare coverage better involves knowing if you qualify for these programs and how Medicare and OHP work together. This knowledge can be beneficial in navigating the complexities of healthcare. By understanding the eligibility criteria for these programs, you can determine if you are eligible for them. Additionally, comprehending how Medicare and Medicaid collaborate can provide insights into the extent of your healthcare coverage.
Medicare and OHP
Medicare and OHP differ in their eligibility requirements. Medicaid is based on income, whereas Medicare is determined by age or disability status. People who have both Medicare and Medicaid are usually enrolled in a program that offers financial assistance for healthcare expenses. This program gives money to help pay for expenses. Medicare pays for hospital and medical care, like doctor visits, equipment, and outpatient care.
If you qualify for both Medicare and Medicaid, these programs work together to cover the services you need in several ways:
1. Financial Assistance: Individuals with both Medicare and Medicaid are usually automatically enrolled in a program that offers financial aid for healthcare expenses. Depending on your circumstances, you may fall into one of these programs:
The Qualified Medicare Beneficiary (QMB) program assists with paying Medicare cost-sharing such as deductibles, coinsurance, and copays for both Part A and Part B. Enrollment in this program is income-dependent, and it also automatically enrolls you in the Extra Help prescription drug program.
The Specified Low-Income Medicare Beneficiary (SLMB) program helps with Part B premiums and includes automatic enrollment in Extra Help.
The Qualifying Individual (QI) program aids with Part B premiums, but you need to reapply for benefits each year.
The Qualified Disabled and Working Individuals (QDWI) program is designed for individuals with disabilities under age 65 and helps pay for Part A premiums.
OHP can also assist with paying the Medicare Part B premium, Part B deductible, Part A deductible, copays, and coinsurance for Part A and Part B services.
2. OHP can assist in care coordination. In certain states, you might be required to enroll in Medicaid private health plans or Medicaid Managed Care (MMC) plans. These plans may offer the option to join a Medicare Advantage plan, aiming to improve the coordination of care and combine Medicare and Medicaid benefits effectively.
3. OHP can provide coverage for services that are not included in Medicare. While Medicare generally covers most of your healthcare needs, there are certain services it does not cover. In such cases, OHP can be beneficial as it covers some of these additional services, including
nursing home care,
dental care,
transportation,
eyeglasses,
physical therapy, and
other services.
It’s crucial to understand that becoming eligible for Medicare does not result in losing Medicaid eligibility. As long as your income meets the Medicaid eligibility requirements in your state, you can continue to receive both Medicare and Medicaid coverage.
Medicare and Medicaid Dual Eligibility
Some individuals may be eligible for both Medicare based on age or disability and Medicaid based on income or other state requirements. When you have dual eligibility for both Medicare and Medicaid, most of your healthcare costs are likely to be covered, and you may not have to pay anything out-of-pocket.
With dual eligibility, you can choose to receive your Medicare coverage through Original Medicare or a Part C Medicare Advantage plan. Additionally, you’ll receive your Part D prescription drug benefits through Medicare, automatically qualifying for Extra Help to assist with your Part D coverage costs. However, it’s essential to note that despite receiving Extra Help, you still need to select and enroll in a Part D drug plan.
Dual eligibility can fall into two categories:
Full benefit dual eligible, which means you have comprehensive Medicaid coverage.
Partial dual eligible, which means you’ll receive assistance with Medicare premiums and other cost-sharing.
What are Dual Health Plans?
Dual health plans are specially designed for individuals who are dual eligible and have both Medicare and OHP. They belong to a specific type of Part C (Medicare Advantage) plan that combines hospital, medical, and prescription drug coverage. In many cases, these plans have a $0 premium, making them a cost-effective choice.
Private insurance companies offer these dual health plans, allowing you to find one that best suits your coverage and healthcare needs.
In Oregon, Medicaid works alongside Medicare to provide comprehensive health coverage for eligible individuals. The Oregon Health Authority plays a crucial role in managing these programs and ensuring smooth enrollment processes. During the designated enrollment period, individuals can apply for and choose from various health insurance plans that suit their specific healthcare needs.
For those enrolled in Medicare, Medicaid offers additional support through the Oregon Health Plan (OHP). Individuals with end-stage renal disease (ESRD) can benefit from specialized coverage under OHP, tailored to meet their unique medical requirements. This integration ensures that individuals receive coordinated care, optimizing their overall health outcomes.
How to Determine if You’re Dual Eligible
Eligibility requirements for dual eligibility can vary from state to state, typically taking into account your income and financial assets. You can contact your state’s Medicaid office to determine if you qualify for both Medicare and Medicaid.
Generally, beneficiaries with earnings below 138% of the federal poverty level are eligible for both programs. Some states may have additional requirements, such as meeting a limited savings threshold. Seniors living in nursing homes are often dual eligible due to their age and financial circumstances.
Is Medicare or OHP the Primary Insurer?
If you have both Medicare and OHP, Medicare takes precedence as the primary insurer and will be the first to pay for covered services. Medicaid, as the secondary insurer, will pay after Medicare, employer group health plans, and/or Medicare Supplement (Medigap) insurance have made their payments.
However, OHP can cover certain services that Medicare does not, like nursing home care. In such cases, OHP would be the primary payer for those specific services, while Medicare remains the primary payer for any other Medicare-covered services received.
Additionally, OHP can help with other out-of-pocket expenses such as Medicare premiums, deductibles, and copays.
Need help? Call Health Plans in Oregon: 503-928-6918. Our assistance is at no cost to you.
