Navigating the health care system can be challenging for anyone, but for the more than 9 million people who are eligible for both Medicare and Medicaid, it can be especially difficult.
Medicare and Medicaid have similar names but are actually very different programs. People who are eligible for both, known as “dual eligibles,” must understand the differences in eligibility requirements and coverage details in order to access the health care services that are available to them. This is especially important for the 60 percent of dual eligibles who suffer from multiple chronic conditions, such as diabetes and heart disease. Getting the health care coverage they need to appropriately manage their conditions is critical to their well-being.
The 211,378 dual eligibles in Wisconsin and their caregivers should take the following steps to help simplify their health care experience and get the best care available.
1. Understand the differences in coverage and eligibility between Medicare and Medicaid.
Medicare is a program managed by the federal government that provides health care benefits to people age 65 and older and disabled individuals. Medicare covers medical care services such as physician visits, hospital stays and prescription drug costs.
Medicaid is a health care benefits program managed by the Wisconsin state government. Unlike Medicare, each state sets its own guidelines regarding Medicaid eligibility and services. For those enrolled, Medicaid pays for most long-term care as well as Medicare deductibles, co-payments and other health care costs that beneficiaries would otherwise pay for out of pocket.
2. Explore health care options in Wisconsin that provide adequate support for dual eligibles.
For dual eligibles, the coordination of benefits between Medicare and Medicaid can be confusing, as beneficiaries typically have separate membership cards and different points of contact for their benefits questions. One option to address this challenge that has risen to the forefront of Wisconsin efforts in recent years is what’s known as a Medicare Advantage Special Needs Plan.
Offered by private companies, these plans can be chosen in place of traditional Medicare. Special Needs Plans support dual-eligible individuals by serving as a single entity that coordinates all aspects of care. These plans focus on the unique needs of dual eligibles, offering customized care and support to manage their complex health care needs. Specialized services available with Special Needs Plans may include in-home visits, social support services and help when transitioning home from the hospital.
3. Learn more by taking advantage of the free resources in your community.
As state and federal officials work to improve the system that supports dual eligibles, residents should be aware of new options available to suit their unique needs as well as resources they can use to learn more. For more information on Medicare and the Wisconsin Medicaid program, residents may contact 1-800-MEDICARE (TTY users should call 1-877-486-2048, 24 hours a day, seven days a week) or 1-800-362-3002. The State Health Insurance Assistance Program, sometimes called SHIP, can also be a good place to turn for free counseling and support. To contact the SHIP office in Wisconsin, call 1-800-242-1060.
Vicki Ambrosius is the Community Relations Manager for Care Improvement Plus in Wisconsin. Care Improvement Plus provides specialized Medicare Advantage coverage for underserved and chronically ill beneficiaries throughout Wisconsin.
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