Navigating healthcare can be complex, especially for seniors. Many older adults in America rely on government programs to help manage their healthcare costs. Two key programs, Medicare and Medicaid, often work together to provide comprehensive coverage, particularly for those with limited income and resources. This article explains how these programs interact to support senior healthcare needs.
Medicare, a federal health insurance program, is primarily for individuals 65 and older, regardless of income. It is divided into four parts, each covering different aspects of healthcare:
- Part A (Hospital Insurance): This covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.
- Part B (Medical Insurance): Part B covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
- Part C (Medicare Advantage): These are plans offered by private companies approved by Medicare. They combine Part A and Part B benefits and often include Part D drug coverage.
- Part D (Prescription Drug Insurance): This helps cover the cost of prescription medications.
For seniors with limited financial resources, Medicaid, a joint federal and state program, can provide additional assistance. Many seniors are “dually eligible,” meaning they qualify for both Medicare and Medicaid. In these cases, Medicaid can act as a supplemental insurance to Medicare.
Medicaid offers several forms of help for Medicare enrollees, including Medicare Savings Programs (MSPs). These programs, such as Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) programs, help with Medicare premiums and cost-sharing.
Furthermore, Medicaid can cover services that Medicare doesn’t, such as long-term nursing home care beyond Medicare’s limited coverage, dental and vision care, and hearing aids. When a service is covered by both Medicare and Medicaid, Medicare pays first, and Medicaid may then cover the remaining costs, depending on state rules and payment limits.
The following are theDual Eligible Standards for 2025, based on a percentage of the Federal Poverty Level, to give a clearer picture of income and asset limitations for some of these programs:
2025 Dual Eligible Standards
Qualified Medicare Beneficiary (QMB):
Helps pay for Part A and Part B premiums, deductibles, coinsurance, and copayments.
Monthly Income Limits: (100% FPL + $20)*
| Region | Individual | Couple |
|---|---|---|
| All States and DC(Except Alaska & Hawaii) | $1,325 | $1,783 |
| Alaska | $1,650 | $2,223 |
| Hawaii | $1,520 | $2,047 |
| Asset Limits | $9,660 | $14,470 |
*$20 = Amount of the Monthly SSI Income Disregard
Specified Low-Income Medicare Beneficiary (SLMB):
Helps pay for Part B premiums.
Monthly Income Limits: (120% FPL + $20)*
| Region | Individual | Couple |
|---|---|---|
| All States and DC(Except Alaska & Hawaii) | $1,585 | $2,135 |
| Alaska | $1,975 | $2,663 |
| Hawaii | $1,819 | $2,452 |
| Asset Limits | $9,660 | $14,470 |
*$20 = Amount of the Monthly SSI Income Disregard
Qualifying Individual (QI):
Helps pay for Part B premiums. Note: QI program is often the first to run out of funding.
Monthly Income Limits: (135% FPL + $20)*
| Region | Individual | Couple |
|---|---|---|
| All States and DC(Except Alaska & Hawaii) | $1,781 | $2,400 |
| Alaska | $2,220 | $2,994 |
| Hawaii | $2,044 | $2,756 |
| Asset Limits | $9,660 | $14,470 |
*$20 = Amount of the Monthly SSI Income Disregard
Qualified Disabled Working Individual (QDWI):
Helps pay for Part A premiums for certain disabled individuals who return to work.
Monthly Income Limits: (200% FPL + $20)*(Figures include additional earned income disregards)
| Region | Individual | Couple |
|---|---|---|
| All States and DC(Except Alaska & Hawaii) | $5,302 | $7,135 |
| Alaska | $6,602 | $8,895 |
| Hawaii | $6,082 | $8,192 |
| Asset Limits | $4,000 | $6,000 |
*$20 = Amount of the Monthly SSI Income Disregard
In conclusion, for many of America’s seniors, particularly those with lower incomes, healthcare coverage is provided through a combination of Medicare and Medicaid. Understanding how these programs work together is crucial for accessing comprehensive and affordable healthcare in retirement. Seniors and their families should investigate their eligibility for both programs to ensure they receive the full benefits available to them.
