Obamacare: Medicaid Expansion does not apply to people on Medicare.

Under Obamacare Medicaid is being expanded for people with incomes up to 133% of the federal poverty level.  But this expansion does not apply to people who have Medicare.

There has been a lot of talk in the last few months about how Medicaid expansion would help low-income Medicare beneficiaries, but that was all wishful thinking.

People on Medicare whose income is less than $977 per month are already eligible for help from Medicaid (AHCCCS in Arizona). These people are called “Dual Eligible” because they have Medicare and Medicaid.  Medicaid (AHCCCS) acts as a supplement to Medicare so “Duals” don’t have co-pays for medical services they receive.  These folks are also called “QMBs” (Qualified Medicare Beneficiaries).

People who are Dual Eligible have access to Medicare Advantage plans that provide additional benefits such as dental coverage, transportation to medical appointments, hearing aids, and vision benefits.

People on Medicare with income between $977 per month and $1,293 get help from Medicaid, but only for their Medicare premium. The state Medicaid program will pay their Medicare Part B premium ($104.90 currently).

These folks with very limited income have the usual Medicare co-pays. Many are enrolled in Medicare Advantage plans with co-pays that have gone up each year. Paying $50 to see a specialist is a burden for these people, especially if they need multiple visits. A hospital stay will cost them between $200 and $1,500 and many cannot afford to put out this kind of money.

It is this second group of Medicare beneficiaries that was expected to benefit from Medicaid expansion – or at least that’s what insurance brokers were being told by some Medicare Advantage plans.  But it turns out management at the “Special Needs Plans” (SNPs) was misinformed.  These SNPs (pronounced “snips”) were certainly hoping for a major expansion of their business as  many more low-income Medicare beneficiaries would have qualified for their Medicare Advantage plans. But, alas, it is not to be.

I recently asked a CMS contact if he could get some confirmation on the question of Medicaid expansion and low-income Medicare beneficiaries.  Here is what he got from a CMS Medicaid specialist:


1.  Does the AHCCCS Medicaid expansion affect low-income Medicare beneficiaries in Arizona?

CMS Answer: The AHCCCS Medicaid expansion is effective on 1/1/14 and expands Medicaid eligibility to persons who meet the following requirements:

  • Between 19 – 64 years old
  • Not otherwise mandatorily eligible for Medicaid
  • Income is at or below 133% Federal Poverty Level (FPL)
  • Not pregnant
  • Not eligible or enrolled in Medicare Part A or B
  • Parent or caretaker relative living with a child under age 19 not covered unless the child is receiving Medicaid or CHIP or through the Exchange or otherwise receiving minimum essential coverage as defined in 42 CFR 435.4.

Under the eligibility requirements above, it would be unlikely that a low-income Medicare beneficiary would be eligible for Medicaid through the Medicaid new adult expansion category.  However, there may be other Medicaid eligibility categories through which that the Medicare member may qualify for AHCCCS Medicaid, such as being at risk of institutionalization and meeting the other income and eligibility criteria for that eligibility category.

If a Medicare beneficiary thinks s/he may qualify for AHCCCS Medicaid, more information is available on the AHCCCS website at:  http://www.azahcccs.gov/

The online application for AHCCCS Medicaid is at:  https://www.healthearizonaplus.gov/

2.      Are there other ways that Medicaid (AHCCCS) can help low-income Medicare beneficiaries?

Medicaid beneficiaries who have limited income and resources may get help paying for their Medicare premiums and out-of-pocket medical expenses from Medicaid.  Individuals entitled to Medicare Part A and/or Part B and eligible for some form of Medicaid benefits are often referred to as “dual eligibles.”  These benefits are referred to as Medicare Savings Programs (MSP) and cover low-income Medicare beneficiaries’ Medicare premium and/or cost-sharing under 4 eligibility categories:

  • Qualified Medicare Beneficiary Program (income <=100% FPL),
  • Specified Low-Income Medicare Beneficiary (SLMB) Program (income between 100% – 120% FPL)
  • Qualified Individual (QI) (income between 120-135% FPL)
  • Qualified Disabled Working Individual (income <=200% of SSI limit)

It’s possible for a person to be a “QMB Plus” or “SLMB Plus” – these persons would be entitled to all benefits available to a QMB or SLMB as well as all benefits available under the State Medicaid Plan.  These persons would have to independently meet the financial and other eligibility criteria for full Medicaid coverage under AHCCCS.

A Full Benefit Dual Eligible (FBDE) does not meet the income or resources criteria for a QMB or a SLMB and is eligible for Medicaid either categorically or through optional coverage groups, such as Medically Needy (not covered in Arizona) or special income levels for the institutionalized or home and community-based waivers (Arizona covers home and community-based services under its 1115 demonstration waiver).

Thanks to Ken Gardner, a CMS representative who went out of his way to get this information for me.

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