Can you have Medicare and Medicaid in Texas for seniors?

Did you know that over 12 million Americans are "dually eligible" for both Medicare and Medicaid? For seniors in Texas, understanding if and how you can have Medicare and Medicaid is crucial for managing healthcare costs and accessing comprehensive care.

Quick Summary

Yes, Texas seniors can qualify for both Medicare and Medicaid, a status known as dual eligibility, which provides comprehensive coverage and significant savings on healthcare expenses by coordinating benefits.

Key Points

• Dual Eligibility: Texas seniors can qualify for both Medicare and Medicaid, a status called dual eligibility, to get more comprehensive and affordable healthcare.

• Payer of Last Resort: Medicare pays for covered services first, and Texas Medicaid then pays for the remaining costs and services up to the state's payment limit.

• Qualifying for Both: Eligibility requires meeting federal Medicare criteria and Texas-specific income and resource limits for Medicaid programs.

• Enhanced Benefits: Dual eligibility can cover costly gaps in Medicare, such as out-of-pocket expenses for premiums, deductibles, copayments, and prescription drugs.

• Texas Programs: Specific programs like the Qualified Medicare Beneficiary (QMB) and STAR+PLUS help low-income Texas seniors with medical costs and long-term care services.

• Application Process: Seniors can apply for dual eligibility through the Texas Health and Human Services Commission to determine their qualification for assistance.

Understanding Dual Eligibility for Seniors in Texas

Combining Medicare and Medicaid is a healthcare strategy that can provide comprehensive coverage for eligible seniors in Texas. This status, known as dual eligibility, is for those who qualify for Medicare due to age or disability and also meet the financial criteria for Texas Medicaid. While Medicare primarily covers hospital (Part A) and medical (Part B) services, Medicaid can cover costs and services that Medicare does not, such as long-term care and some out-of-pocket expenses. This coordination of benefits ensures a more complete and affordable healthcare plan for those with limited income and resources.

The Relationship Between Medicare and Medicaid

For dual-eligible individuals, the two programs work together to cover healthcare costs. It is important to understand which program pays first, a concept known as the payer of last resort. Medicare always pays first for covered services, and Medicaid then acts as the secondary payer, covering remaining costs up to the Texas Medicaid payment limit. This can include deductibles, copayments, and coinsurance that would normally be the senior's responsibility. It can also cover benefits not typically included in Medicare, such as certain dental care, vision services, and prescription drugs through Texas Medicaid.

How to Qualify for Both Programs

To be eligible for dual enrollment in Texas, a senior must meet the requirements for both programs.

• Medicare Eligibility: You must be 65 or older, or have received Social Security Disability benefits for at least 24 months, or have End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Most individuals who have paid Medicare taxes for at least 10 years are eligible for premium-free Part A.
• Medicaid Eligibility in Texas: Qualification for Medicaid, which is state-specific, depends on an individual's income and assets. In Texas, there are several programs to assist seniors. Eligibility is based on a set of financial rules, including monthly income limits and resource limits (bank accounts, stocks, etc.). The Texas Health and Human Services Commission (HHSC) oversees these programs and their specific requirements.

The Benefits of Being Dually Eligible

Becoming dually eligible can dramatically improve access to and affordability of healthcare for seniors.

• Comprehensive Coverage: Dual eligibility fills many of the coverage gaps in Original Medicare, providing a more robust safety net for healthcare costs.
• Reduced Out-of-Pocket Costs: Medicaid helps pay for the costs that Medicare doesn't, including premiums, deductibles, and copayments, significantly lowering personal healthcare expenses.
• Prescription Drug Assistance: Those with dual eligibility automatically qualify for Extra Help, a Medicare program that helps with Part D prescription drug plan costs.
• Expanded Service Coverage: Medicaid in Texas can cover services not covered by Medicare, such as long-term nursing facility care, dental services, eyeglasses, and hearing aids.

Texas-Specific Medicaid Programs that Help Seniors

Texas offers several Medicare Savings Programs (MSPs) and other managed care options to help seniors with their healthcare expenses.

1. Qualified Medicare Beneficiary (QMB) Program: For those with very limited income and resources, QMB covers all Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments.
2. Specified Low-Income Medicare Beneficiary (SLMB) Program: This program is for those with slightly higher income than QMB. It covers the Medicare Part B premium only.
3. Qualifying Individual (QI) Program: For those with slightly higher income than SLMB, this program pays for the Part B premium.
4. STAR+PLUS Program: This is a Texas Medicaid managed care program for people with disabilities or those aged 65 and older. It offers a combination of Medicaid acute care and long-term services and supports, allowing individuals to stay in their homes or communities rather than moving to a nursing facility.

How Dual-Eligible Plans Work

When considering your options, it's helpful to understand the different ways these benefits can be structured. This table compares several possibilities for Texas seniors.

Feature	Original Medicare + Texas Medicaid	Medicare Advantage + Texas Medicaid	Standalone Medicare Advantage Plan
Coverage Type	Original Medicare (A/B) with secondary Medicaid	Combines A/B/D, coordinated by a private plan	Private plan for A/B/D benefits
Cost Coverage	Medicaid covers most cost-sharing after Medicare pays.	Medicaid covers most cost-sharing within the managed plan.	Cost-sharing (deductibles, copays) can vary.
Extra Benefits	Limited extra benefits, Medicaid covers long-term care.	Often includes dental, vision, hearing, gym memberships.	Varies by plan, can include dental, vision, hearing.
Managed Care	No, fee-for-service model.	Yes, benefits coordinated by a single managed care plan.	Yes, managed care network.
Long-Term Care	Covered by Texas Medicaid once eligible.	May be covered under the plan or through separate Medicaid programs.	Not covered.

How to Apply for Dual Eligibility

To explore your options and apply for assistance, you will need to contact the Texas Health and Human Services Commission (HHSC). You can start the application process online, by phone, or in person at a local HHSC office. The process will involve submitting information about your income, resources, and household size to determine eligibility for the various Medicare Savings Programs or full Medicaid coverage. The HHSC provides detailed information and assistance to help navigate the enrollment process. For more information, visit the Texas Health and Human Services website.

Conclusion

For many Texas seniors, coordinating Medicare and Medicaid is a powerful way to secure comprehensive and affordable healthcare. Understanding the dual-eligible status and the specific programs available in Texas is the first step toward reducing out-of-pocket costs and ensuring access to a wider range of medical services. By meeting the eligibility requirements for both programs, seniors can gain peace of mind knowing their healthcare needs are covered more completely.

Frequently Asked Questions

What is the difference between Medicare and Medicaid for Texas seniors?

Medicare is a federal health insurance program primarily for people 65 or older. Medicaid is a state-specific, needs-based program that provides healthcare for low-income individuals. Texas seniors who meet the criteria can have both to maximize their benefits.

How do I know if I am eligible for both Medicare and Medicaid in Texas?

To be eligible, you must qualify for Medicare (generally by age or disability) and also meet the income and resource limits set by the Texas Health and Human Services Commission for Medicaid. These limits can change annually.

If I have both, which program pays my medical bills first?

Medicare is the primary payer and will be billed first for covered services. Medicaid is the payer of last resort and will cover most of the remaining costs, such as copayments and deductibles, up to the Texas-allowed amount.

What are Medicare Savings Programs in Texas?

Medicare Savings Programs (MSPs) use Medicaid funds to help eligible low-income individuals pay for Medicare-related costs. Examples in Texas include the QMB, SLMB, and QI programs, which assist with premiums and other out-of-pocket expenses.

Can dually eligible seniors get help with prescription drug costs?

Yes. Seniors who are dually eligible automatically qualify for the Extra Help program, which significantly lowers the cost of Medicare Part D prescription drug coverage.

Does dual eligibility affect my Medicare plan options?

Yes. Dually eligible individuals can choose from several options, including Original Medicare with Texas Medicaid, a Medicare Advantage plan that includes Medicaid benefits, or specific programs like STAR+PLUS managed care.

How can I apply for dual eligibility in Texas?

You can apply through the Texas Health and Human Services Commission (HHSC) online via their website, over the phone, or in person at a local office. The application will assess your financial situation to determine your eligibility.