Adult Medicaid Manual MA-2410 MEDICARE ENROLLMENT & BUY-IN

REVISED 01/01/07 – CHANGE NO.02-07

I. INTRODUCTION

A. What is Medicare?

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:

1. Part A, Hospital Insurance

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.

2. Part B, Supplementary Medical Insurance

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.

3. Part C, Medicare Advantage Insurance

Part C allows beneficiaries to enroll in additional types of health plans, including managed care plans.

4. Part D, Medicare Prescription Drug Plan

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

(I.)

B. Medicaid Supplements Medicare Payments for Medical Services

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.

C. Medicaid will Pay Medicare Premiums

1. Most people who have Medicare Part A, Hospital Insurance, do not pay monthly premiums since they have credits for work under Social Security. Those who do not have work credits must pay a monthly premium. However, if the person is enrolled in Medicare Part B, Supplementary Health Insurance, and is eligible for Qualified Medicare Beneficiary Coverage (Q classification), Medicaid pays his Part A premium. (Refer to MA-2130, Qualified Medicare Beneficiaries-Q.)

2. There is a monthly premium for Part B. The premium is deducted from the Social Security check, or billed quarterly to those persons who do not receive monthly Social Security benefits, but who qualify and are enrolled in Medicare Part B. Medicaid pays the Part B premium for Medicaid recipients eligible for Part B coverage.

The payment of Medicare premiums by Medicaid is referred to as the “Medicare Buy-In.”