I’m a District resident and I have
both Medicare and Medicaid. Which
is which? And which does what?
Medicare is a federal program that provides medical
coverage to people who qualify, mainly people over
65 or people with disabilities. Medicare covers routine
and acute medical care, like doctors’ visits and
hospital stays.
In the District, there are a few different ways Medicare
might provide you coverage.
Many people have Medicare “fee-for-service,” which
is sometimes called “original Medicare.” If you have
this coverage, you likely have a red, white, and blue
card that says “Medicare
Health Insurance” at the top.
This coverage pays for
inpatient and outpatient
medical care.
Other people get their Medicare benefits through a
private health plan. This may be Kaiser Permanente,
Aetna, or another company. These plans provide the
same benefits you get through Medicare fee-for-
service. They might also offer other services and may
provide you with a care manager.
A couple of these health plans, United HealthCare
and Cigna, have a special agreement with the
District’s Medicaid agency. This agreement allows
them to provide services to people enrolled in both
Medicare and Medicaid. Like the other health plans,
they provide the same benefits you get through
Medicare fee-for-service. However, they can offer
supplemental benefits and help coordinate your care.
If you enroll in a private health plan, you may not have
access to all the health care providers you can access
in Medicare fee-for-service. Still, each health plan
must have enough doctors and other providers to
serve its patients.
Finally, you may have a separate
company helping with your
prescription drug (Part D) benefits.
Or, it might be the same company
that provides your other Medicare
benefits.
Medicaid is a program run by each state, coordinated
with the federal government. It provides medical
coverage to people who qualify due to their income,
disabilities, age, or other factors. Like Medicare,
Medicaid covers basic medical benefits, but it also
covers many things Medicare doesn’t cover. For
example, it covers long-term care, dental care,
hearing, and vision benefits. For people enrolled in
both programs, Medicaid coverage “wraps around”
Medicare benefits. This means both programs share
the responsibility of providing health care coverage.
In the District, there are different ways you might have
Medicaid coverage, just like with Medicare. Private
Medicaid health plans cover almost 80 percent of
people enrolled in District Medicaid. These health
plans – such as AmeriHealth Caritas DC and MedStar
Family Choice – cover all Medicaid services.
However, these plans do not usually cover people
who have both Medicare and Medicaid.
People who have Medicare may enroll in Medicaid
fee-for-service (also sometimes called “straight
Medicaid”). Many people who have disabilities or are
elderly enroll in a Medicaid waiver program. Waivers
can provide additional benefits and services for
people who need them. In the District, we have three
waiver programs: EPD, IDD, and IFS. The EPD
waiver serves people who are elderly or who have
physical disabilities. The IDD and IFS waivers support
people who have intellectual or
developmental disabilities and
their families.
Some people who have help from
both Medicare and Medicaid
have complete Medicare
coverage, but they do not have
access to Medicaid benefits. These people are
usually described as “QMBs” (Qualified Medicare
Beneficiaries). While they don’t qualify for Medicaid
benefits, the Medicaid agency does help pay for their
Medicare benefits.
I heard there are changes coming in 2022 to
Medicare and Medicaid. What is changing? What
do I need to do?
More than 36,000 people live in the District who have some form of Medicare coverage and some kind of Medicaid
coverage. It can be confusing and complicated when you have more than one kind of health care coverage. The
District government wants to make it easier for people to find and get services they need. To do that, the DC
Department of Health Care Finance (DHCF), which is the Medicaid agency for the District of Columbia, is starting
new programs and expanding existing programs.
If you are currently enrolled in United or Cigna for your
Medicare benefits, talk to the health plan or your care
team about how services might change in 2022. If you
are enrolled in both United or Cigna and the EPD
waiver, talk with your EPD waiver case manager, too.
If you are interested in learning more about Dual Choice or PACE so that you can consider enrolling in 2022,
talk to your health care providers or the DC State Health Insurance Program (SHIP, 202-727-8370).
The Program of All-Inclusive Care for the Elderly
will be coming to the District for the first time in
2022. PACE is a model that has been in place in
other states for many years, and the District’s first
PACE program will serve Wards 7 and 8. PACE is
unique in several ways. It allows for integration of
Medicare and Medicaid services into a “one-stop
shop.” This occurs at a community-based PACE
Center which includes an “interdisciplinary care
team” or IDT. The IDT has 11 different PACE
program team members who work together to
make sure PACE participants’ needs are met.
If you enroll in PACE, you may not be able to
access other services you use now, because your
provider may not work with the PACE team.
However, the PACE program must offer all
Medicare and Medicaid services. They will work
with you and your family to make sure all the
services needed to keep you safe and healthy in
the community are included in your service plan.
PACE
The District is expanding its current Dual Choice
program with special Medicare Advantage health
plans. United HealthCare and Cigna are our current
health plans in this program. Currently, people
enrolled in both Medicare Advantage and Medicaid
access their Medicaid benefits through fee-for-
service Medicaid and their Medicare benefits
through the health plan. In 2022, the health plans
will also provide Medicaid benefits, combining both
sets of services into a “one-stop shop.” This will
allow the health plans to offer more coordinated
benefits across the two programs.
If you enroll in Dual Choice, you may not be able to
access other services you use now, because your
provider may not work with the health plan. If you
are already enrolled in Dual Choice for your
Medicare benefits, you may experience changes in
your Medicaid benefits (such as home health or EPD
waiver benefits). However, you will still be entitled to
all Medicare and Medicaid services. The Dual
Choice plan will work with you and your family to
make sure all the services needed to keep you safe
and healthy in the community, delivered by a
provider you choose, are included in your service
plan.
Dual Choice
