Eligibility for Medicare and Medicaid

Eligibility for Medicare and Medicaid Medicare is the primary payor for a beneficiary who is both Medicare and Medicaid eligible and has four (4) parts: A. Medicare Part A 1. The Division of Medicaid pays for the Medicare Part A premium through a "buy-in" process for individuals who have income that does not exceed 100% of the poverty level and are classified as Qualified Medicare Beneficiaries (QMB) and QMB-dual recipients, meaning the recipient is dually eligible as both a QMB and has full Medicaid through other coverage. 2. The Centers for Medicare and Medicaid Services (CMS) and the Division of Medicaid work jointly to ensure that all eligible individuals are included in the "buy-in" process for Medicare coverage. Persons who may be Medicaid-eligible should apply at the appropriate certifying agency. B. Medicare Part B 1. The Division of Medicaid pays the Medicare Part B premium through a "buy-in" agreement with the Social Security Administration (SSA) for all Medicaid eligible individuals who also qualify for Medicare Part B. CMS and the Division of Medicaid work jointly to ensure that all eligible individuals are included in the "buy-in" process. 2. The Division of Medicaid also pays Part B premiums for specified low-income Medicare beneficiaries (SLMBs) and certain qualifying individuals (QIs). SLMBs and QIs do not receive a Medicaid ID card or any other benefits. C. Medicare Part C (Medicare Advantage Plans) 1. The Division of Medicaid pays for the Medicare Part C coinsurance and deductible for beneficiaries in applicable Categories of Eligibility (COE). 2. For purposes of reimbursement, co-payments charged by a Medicare Part C plan are considered to be coinsurance. D. Medicare Part D (Medicare Prescription Drug Plan) 1. When Medicaid beneficiaries have both Medicare and Medicaid coverage, pharmacy providers are required to bill Medicare for drugs covered by that program. 2. The Division of Medicaid considers the Medicare payment as payment in full for Medicare Part D pharmacy claims.