REVISED 01/01/07 – CHANGE NO. 02-07
Some Medicaid recipients are eligible for medical benefits from Medicare. Medicare is a health insurance program authorized by Title XVIII of the Social Security Act. It is administered by the federal Centers for Medicare and Medicaid Services (CMS) in Baltimore, Maryland. People who are age 65 or over, people under age 65 who have been entitled to disability benefits under the Social Security or Railroad Retirement program for 24 months, and some people with renal disease are eligible.
Medicare has four parts:
Part A covers medically necessary inpatient hospital services and care in a skilled nursing facility after hospitalization. It also helps cover hospice care and some home health care.
Part B covers medically necessary physician's services, outpatient hospital services, outpatient therapy and speech pathology services. It also covers other medical services such as laboratory, X-rays and medical supplies, and home health services when the individual does not have Part A.
Part C allows beneficiaries to enroll in additional types of health plans, including managed care plans.
Part D Medicare Prescription Drug plan covers both brand-name and generic prescription drugs at participating pharmacies.
REISSUED 01/01/07 – CHANGE NO. 02-07
For Medicaid recipients who are covered by Medicare, Medicare is the primary payor. This means that Medicare pays before Medicaid. Medicare pays the amount that it will pay for a service that it covers. If the service is covered by Medicaid and Medicare does not pay as much for the service as Medicaid pays or the Medicare payment is reduced by a deductible or co-payment, Medicaid pays for the portion of the cost of the service up to the Medicaid allowable that Medicare did not pay.
It is important that Medicaid recipients who are also eligible for Medicare are enrolled in Medicare. The Medicare payment reduces the amount that Medicaid must pay for the service. If a Medicaid recipient who is over age 65 is not enrolled in Medicare Part B, Medicaid does not pay any portion of services that would have been covered by Medicare Part B.
The payment of Medicare premiums by Medicaid is referred to as the “Medicare Buy-In.”
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.