Do You Need Medigap if You're Eligible for Both Medicare and Medicaid?
Fair Square Medicare

Do You Need Medigap if You're Eligible for Both Medicare and Medicaid?

A person with a shopping cart already containing medicaid and medicare sees Medigap options on a table. In a thought bubble, they ask "Should I get Medigap too?"

By Daniel Petkevich

Jan 7, 2023

You may enroll in more than one plan, but you don't need all three. Here's why:

Medicare, Medicaid, and Medigap (also known as Medicare Supplement) often overlap; sometimes, people sign up for more than one plan. But is there ever a time when you should enroll in all three?

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We want you to get the best benefits possible, so we'll walk you through everything you need to know.

Let's explore Medicare, Medicaid, and Medigap in more detail, get a sense of their differences, and discuss whether to enroll in more than one plan.

What's the Difference Between Medicare, Medicaid and Medigap?

Medicare, Medicaid and Medigap all assist in covering your healthcare expenses. But they help different populations and meet unique needs.

Let's take a look at each plan.

Medicare

Medicare is a health insurance program administered by the U.S. federal government.

It provides coverage to people ages 65+ and those with disabilities or ESRD (end-stage renal disease).

There are four parts to Medicare:

  • Part A — part of Original Medicare; covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home healthcare

  • Part B — part of Original Medicare; covers medically necessary services and preventive care, such as doctor visits, lab tests, and durable medical equipment

  • Part C (Medicare Advantage) — alternative to Parts A and B offered by private insurance companies; combines all the benefits of Parts A and B and often includes additional benefits, such as prescription drug coverage

  • Part D — prescription drug benefit that can be added to Original Medicare (Parts A and B) or a Part C plan

Medicaid

Medicaid is a joint federal and state program that provides health insurance to low-income individuals and families — including the elderly, individuals with disabilities, children, and pregnant women.

Medicaid might cover a wide range of medical services, such as:

  • Doctor visits

  • Hospital stays

  • Prescription drugs

  • Long-term care

  • Immunizations

  • Screenings

Medicaid is administered by the states (rather than at a federal level). And each state has its own eligibility criteria and benefits. To be eligible for Medicaid, you must meet your state's income and asset requirements.

Medigap

Medigap is a supplemental insurance policy that supplements Original Medicare (Part A and Part B).

It helps cover certain out-of-pocket costs — like copayments, coinsurance, and deductibles. However, it doesn't cover long-term care, vision, dental, hearing aids, private-duty nursing, and prescription drugs.

Medigap policies are offered by private insurance companies and are standardized by the federal government. You can choose from 10 Medigap plans depending on your requirements. Medicare Supplement Plan G offers the most comprehensive coverage for many of our clients.

Can I Get Both Medicare and Medicaid Benefits Together?

Yes. You can benefit from Medicare and Medicaid if you're dually eligible. In other words, you have to meet the eligibility requirements for both Medicare and Medicaid.

To be dually eligible, you must meet the following conditions:

  • Be 65 years or older or have a disability (like ESRD)

  • Have a low income

How Do Medicare and Medicaid Work Together?

Medicare covers 80% of your healthcare expenses, while Medicaid helps cover the remaining out-of-pocket costs left by Medicare Parts A and B.

In other words, Medicare covers services that Medicaid doesn't and vice versa.

For example, Medicare may cover your hospital stays, doctor visits, and lab tests, while Medicaid covers your additional expenses like premiums, prescription drugs, eyeglasses, hearing aids and long-term care. Both work together to maximize your benefits and provide comprehensive coverage.

To better understand how these two programs work together, you need to be familiar with two terms: coordination of benefits and crossover claims.

What Is Coordination of Benefits?

When a person has multiple health insurance plans (like Medicare and Medicaid), providers must coordinate their benefits to avoid overpaying or duplicating coverage. Coordination of benefits determines which health insurance plan should pay for a medical service or claim first.

  • "Primary" payer — the insurance plan that pays first

  • "Secondary" payer — the plan that pays second

In general, Medicare is the primary payer, and Medicaid is the secondary payer. This means Medicare will pay for covered medical services first, and Medicaid will pay for any remaining expenses not covered by Medicare — like copayments, deductibles and coinsurance.

What's a Crossover Claim?

A crossover claim is a medical claim submitted to multiple insurance plans. They're used when an individual has two insurance plans that coordinate their benefits.

For example, if you’re enrolled in both Medicare and Medicaid, your provider will submit the claim to Medicare. Medicare will process the claim first and apply any deductibles, coinsurance, or copayments. The claim will then be automatically forwarded to Medicaid. (Note: Your provider doesn't have to bill Medicaid separately for the deductible, coinsurance, or copayments that Medicare applied).

Is Medigap Necessary If You Are Eligible for Both Medicare and Medicaid?

No. You don't need to enroll in a Medigap Plan if you're enrolled in Medicare and are eligible for full Medicaid benefits.

Here's why:

  • Most of your medical expenses are likely covered if you're dually eligible for Medicare and Medicaid

  • Insurance companies aren't permitted to sell Medigap policies to Medicare beneficiaries with full Medicaid coverage

I Don't Qualify for Medicaid. Can I Still Get a Medigap Plan?

Yes! Medigap plans are good for individuals who don't qualify for Medicaid. They're especially helpful if you have a high income or assets and need help with out-of-pocket costs not covered by Original Medicare (Parts A and B).

Takeaway

Medicare, Medicaid, and Medigap are all health insurance programs that cover your medical expenses. Medicaid is specifically designed to help low-income individuals pay for out-of-pocket costs. In contrast, Medigap plans often help high-income individuals — who aren't eligible for Medicaid — pay for their out-of-pocket costs.

You don't need to enroll in a Medigap Plan if you're eligible for both Medicare and Medicaid. Medicaid will likely cover most of your out-of-pocket expenses.

Having multiple health insurance plans can give you more comprehensive coverage. But it can also be confusing. At Fair Square Medicare, we have helped thousands of beneficiaries understand the ins and outs of Medicare and make informed decisions about their coverage. If you have any questions, give us a call at 1-888-376-2028.

Stay up to date on Medicare

Join the Fair Square Medicare Newsletter to stay informed on cost savings, changes to Medicare, and other valuable healthcare information.


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