This section will present brief descriptions and some basic differences between Medicaid and Medicare.
Medicaid:
Medicaid is the most comprehensive public health insurance program. Medicaid is a jointly funded, Federal-State health program for certain low-income individuals and families who fit into certain eligibility group. Low-income people with disabilities are one such targeted group.
Medicaid can cover doctor visits, hospitalization, prescription drugs, mental health services, dental care, vision care, alcohol and drug treatment, equipment and supplies, and transportation to medical appointments. There may be premiums, deductibles, or co-pays for Medicaid or services covered by Medicaid.
Medicaid may be accessed by people with disabilities in several ways. In Wisconsin, anyone who receives Supplemental Security Income (SSI) automatically qualifies for Medicaid. If a person with a disability does not qualify for SSI, he or she may apply for other Medicaid programs through County or Tribal Human Services. These programs include Special Status Medicaid programs, Categorically Needy Medicaid, Medically Needy Medicaid (Deductible Medicaid), and MAPP.
Persons with disabilities must demonstrate financial need (assets and income) to be eligible for Medicaid. For assets, most Medicaid programs for persons with disabilities have a $2,000.00 asset limit for individuals, and $3,000.00 limit for couples. The exception to this is the Medicaid Purchase Plan (MAPP), which has a $15,000.00 asset limit.
Income eligibility criteria varies across programs. Individuals with disabilities who want to work should be aware of the specific Medicaid program they participate in, and how earning income may affect eligibility for this program. You may need the assistance of a Work Incentive Benefits Counselor <link to accessing WIB in Wisconsin> to help determine your specific Medicaid program and how earned income may affect eligibility.
There are 2 major work incentive Medicaid programs which help protect Medicaid eligibility for individuals with disabilities who work.
- Continued Medicaid Eligibility 1619(b): Allows Medicaid coverage to continue when work earnings cause an SSI payment to be reduced to $0.00.
- Medicaid Purchase Plan (MAPP): A Medicaid program designed for people with disabilities who work. Income and asset levels for eligibility are significantly higher than other Medicaid programs. Adjusted income limit for eligibility is 250% of the Federal Poverty Level, and asset limit is $15,000.00.
Medicaid Waiver Programs
For people with disabilities who require long term care services (e.g. supportive home care services, specialized transportation, home modifications, independent living, residential, transportation, case management, or vocational services), Medicaid eligibility is extremely important. Medicaid can fund longterm care services if the person demonstrates a need for a skilled nursing level of care. If a person demonstrates this need, he or she may qualify for a Medicaid Waiver program.
Medicaid Waiver participants are classified into one of three eligibility groups:
Group A |
Individuals who are eligible for Medicaid through another source. The other Medicaid sources include:
Individuals in Group A are eligible for Medicaid Waiver services with NO cost share. |
Group B |
Group B is for individuals who are not eligible for Medicaid in another way. To be eligible for Group B, an individual’s gross monthly income must be less than 300% of the current SSI Federal Benefit Rate ($1,911.00 in 2008). Individuals in Group B may have a cost share for waiver services. |
Group C |
Group C is for individuals who are not eligible for Medicaid in another way, and have monthly income that is greater than 300% of the Federal Benefit Rate ($1,911.00 in 2008). These individuals must have service-related costs that reduce their countable income below $591.67 (the Medically Needy income limit). This is often referred to as a “spend down”. Individuals in this Group B may have a cost share in addition to a spend down. |
A Medicaid Waiver recipient who works or wants to work should know which eligibility group he or she participates in. Earning income through work may affect a person’s waiver eligibility group. Consult a WIB to determine the affect of additional earned income on Waiver eligibility.
Medicaid Links:
- DHS ACCESS program, an online tool to apply for and check on Medicaid benefits: http://access.wisconsin.gov
- Medicaid Eligibility Handbook: http://www.emhandbooks.wi.gov/meh/
- Centers for Medicaid and Medicare Services: http://www.cms.hhs.gov/
Medicare:
Medicare is a federal health insurance program administered by the federal Center for Medicare and Medicaid Services (CMS). Individuals who receive SSDI are eligible for Medicare coverage after receiving SSDI payments for 24 months. Medicare coverage has three parts: Part A, Part B, and Part D. Medicare provides some basic coverage of health care costs but does not cover all medical expenses.
Medicare Part A: Medicare Part A is Hospital Insurance (HI), covering inpatient medical care. Part A is premium-free to SSDI beneficiaries receiving cash payments. Part A does not cover all hospital costs.
Medicare Part B: Medicare Part B is Supplemental Medical Insurance (SMI), covering outpatient medical care. There is a monthly premium of $96.40 in 2008. Medicare Part B will pay 80% of approved outpatient services.
Medicare Buy-In Programs.
Certain individuals are eligible for programs in which the Wisconsin Medicaid Program pays for some or all of a Medicare beneficiary’s Medicare premiums, deductibles and co-payments. These programs, frequently referred to as "Medicare Buy-In Programs” or “Medicare Savings Programs” programs. These programs are summarized in the table below. These programs are administered by County or Tribal Economic Support Offices.
Asset eligibility for all of the Medicare Buy-In programs is $4,000.00 for an individual and $6,000.00 for a couple.
| Medicare Buy-In Program | Coverage | Eligibility |
Qualified Medicare Beneficiary (QMB) |
Parts A and B premiums, co-pays and deductibles |
SSI recipients or Special Status Medicaid recipients have categorical eligibility. Other with countable income less than 100% of the Federal Poverty Level ($866.67 for an individual in 2008) |
Special Low Income Medicare Beneficiaries (SLMB) |
Part B premium |
Countable income less than 120% of the Federal Poverty Level ($1,040.00 for an individual in 2008) |
Special Low Income Medicare Beneficiaries Plus (SLMB+) |
Part B premium |
Countable income less than 135% of the Federal Poverty Level ($1,170.00 for an individual in 2008) |
Medicare Part D: Medicare Part D is Prescription Drug Coverage. Drug coverage is provided through private Prescription Drug Plans (PDP). Each plan works with a network of pharmacies and has its own drug formularies (list of covered drugs).
People who also receive Medicaid are considered “dually eligible.” Dual eligibles are automatically enrolled in a PDP if one is not chosen. Dual eligibles can change plans as often as one time per month. Plans are described in the Medicare and You Handbook available online at www.medicare.gov. Dual eligibles are also eligible for the Medicare Part D low-income subsidy. They are not be responsible for premiums or deductibles, and will have no gap in coverage. You will be responsible for co-pays for individual prescriptions.
Extended Period of Medicare Coverage (EPMC). Medicare coverage will continue for at least 93 months following the completion of the SSDI Trial Work Period, even if your SSDI payments have ceased due to work earnings. It may continue, depending on when the individual had earnings that were considered SGA. This period of coverage is referred to as the Extended Period of Medicare Coverage (EPMC) work incentive. When the EPMC ends, you have the option of purchasing Medicare coverage.
Medicare links/resources:
- The official Medicare website: www.medicare.gov. Includes tools for accessing information of Part D Prescription Drug Plans in Wisconsin, and allows you to enroll in a Part D Plan.
- Disability Rights Wisconsin’s Disability Drug Benefit Helpline: 1-800-926-4862. Provides information and counseling about Medicare Part D.
- Wisconsin Medigap Helpline: 1-800-242-1060. Provides information and counseling about Medicare.