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Dual Coverage – PACE

Medicare and Medicaid Dual Coverage

Senior at Ranch for Medicaid ImageGuess what? You may be eligible to receive both Medicare and Medicaid coverage! If you have limited income and resources, you may qualify for Medicaid, help in paying for your the premiums, and out-of-pocket medical expenses.

For information on qualifying monthly income limits for dual coverage, go to http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Population/Medicare-Medicaid-Enrollees-Dual-Eligibles/Seniors-and-Medicare-and-Medicaid-Enrollees.html

When a Medicare beneficiary begins receiving Medicaid benefits, they are referred to as a Dual Eligible. Dual Eligibles have more extensive benefits. Medicare is the primary insurer so you are allowed to see Medicare providers; you are not limited to Medicaid doctors. Medicaid is considered the secondary insurer and coverage extends to expenses not covered by Medicare. This includes nursing facility care beyond the 100-day limit or skilled nursing facility care that Medicare covers, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the state’s payment limit.

Medicaid Coverage for Medicare Enrollees is as follows:

  • Part A: Hospitalization costs
  • Part B: Physician services, lab and x-ray services, durable medical equipment, and outpatient and other services
  • Part C: Medicare Advantage Plan (like an HMO or PPO) offered by private companies approved by Medicare
  • Part D: Assists with the cost of prescription drugs

If you are a dual eligible, your Part B Medicare premium and Part D prescription premium are paid/subsidized. Co-pays for prescriptions medicine reduce to $1 and $5. And depending on your personal circumstances, Medicaid may also provide long-term care services.

Program of All-Inclusive Care for the Elderly (PACE) Benefits

PACE offers seniors benefits above and beyond Medicare and Medicaid benefits.Ever heard of the Program of All-Inclusive Care for the Elderly (PACE)?  It provides comprehensive long term services and supports Medicaid and Medicare enrollees.  Healthcare professionals work on your behalf to coordinate all of your care needs now and into the future.  And in most cases you can usually receive care at home. The focus of every PACE organization is to help you live in the community for as long as possible.  Care may also offer services in your community or at one of their centers.  PACE centers meet state and Federal safety requirements and include adult day programs, medical clinics, activities, and occupational and physical therapy facilities.  If an enrollee does need nursing home care, the program pays for that too and continues to coordinate your care.  You are not contractually bound so can leave the program at any time if you so choose.

To be eligible, you must be:

  • Age 55 or older
  • Live in the service area of a PACE organization
  • Eligible for nursing home care
  • Be able to live independently

The PACE model of care uses Medicare and Medicaid funds to cover all of your medically-necessary care and services. You can have either Medicare or Medicaid or both to join PACE.  This enables states to provide PACE services to Medicaid beneficiaries as state option.

Services include but aren’t limited to the following:

  • Primary Care (including doctor and nursing services)
  • Hospital Care
  • Medical Specialty Services
  • Prescription drugs – If you join a PACE program, you’ll get your Part D-covered drugs and all other necessary medication from the PACE program.  If you are in a PACE program, DO NOT join a separate Medicare drug plan. Otherwise, you will lose your PACE health and prescription drug benefits.
  • Nursing Home Care
  • Emergency Services
  • Home Care
  • Physical therapy
  • Occupational therapy
  • Adult Day Care
  • Recreational therapy
  • Meals
  • Dentistry
  • Nutritional Counseling
  • Social Services
  • Laboratory / X-ray Services
  • Social Work Counseling

PACE also covers all other services determined necessary by your team of healthcare professionals to improve and maintain your overall health.

If you have a limited means of transportation, PACE organizations provide all medically-necessary transportation to a PACE center for activities or medical appointments. You can even get transportation to other appointments in the community.

If you qualify for Medicare, all Medicare-covered services are paid for by Medicare.  If you also qualify for your State’s Medicaid program, you will either have a small monthly payment or pay nothing for the long-term care portion of the PACE benefit. If you don’t qualify for Medicaid you will be charged a monthly premium to cover the long-term care portion the PACE benefit and a premium for Medicare Part D drugs. However, in PACE there is never a deductible or copayment for any drug, service, or care approved by your team.

Detailed information can be found at cms.gov Programs of All-Inclusive Care for the Elderly (PACE) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pace111c06.pdf) or call Medicare at 1-800-633-4227.

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