Why Having a Medicare Advantage Plan May Make Sense If You Have Both Medicare and Medicaid

By Rick Beavin, California Market President, Humana


Health benefits can be confusing to navigate, particularly as you become eligible for additional support services. While most Americans 65 and older—or those who qualify due to disability—are eligible for Medicare, some may also be eligible for MediCal, California’s Medicaid program, based primarily on financial need. Individuals who fit into both categories are known as dual eligible, according to the Centers for Medicare & Medicaid Services (CMS).


How do I know if I’m dual eligible?

While dual eligibility does not apply to every Medicare beneficiary, 10.8 million people nationwide are fully or partially dual eligible. It’s important to note that eligibility for Medicare and Medi-Cal are determined separately.


When it comes to Medicare, according to CMS, of the more than 5.6 million Medicare beneficiaries in California, 87 percent are eligible due to age (65 and older), while the remaining 13 percent are eligible due to disability.


When it comes to Medicaid, the income qualifications for Medi-Cal assistance vary, so visit Medicaid.gov or contact your local Medi-Cal office at 1-800-541-5555 to see if you might be eligible.


Why would a Medicare Advantage plan be a good option if I am dual eligible?

If you are dual eligible, signing up for a Medicare Advantage plan can make receiving care more accessible than having traditional Medicare, alone. And, if you are dual eligible, you can sign up for a Medicare Advantage plan once per calendar quarter between January and September, not just during the Annual Enrollment Period (Oct. 15-Dec. 7). Many areas offer Medicare Advantage plans with a $0 premium.


Here’s how having a Medicare Advantage plans over traditional Medicare can help dual eligible individuals make the most of their benefits:


1. Access to dedicated doctor/provider network.

Having a Medicare Advantage Plan means the Medicare Advantage plan becomes your primary health plan for receiving care. These plans typically provide you with a network of doctors and health care providers. Doctors and health care providers know that working with Medicare Advantage plans means their patients will have care coordination and other benefits available through the plan.


It’s important to note that Medicare and Medi-Cal are two entirely different programs that operate under different guidelines; they were not designed to work together. Because of this, your doctor and health care providers may need to coordinate payment for services with both your Medicare Advantage plan and Medi-Cal.


2. The availability of additional benefits.

Medicare Advantage plans often include extra benefits as part of the plan such as dental, vision, and an over-the-counter drug allowance. Many times you will also have access to a fitness benefit that offers free gym membership and access to fitness classes. At the same time, these plans may have simplistic benefit designs that may minimize costs. For example, some Medicare Advantage plans have a $0 copay for doctor visits and $0 or low copays for specialist visits.


3. Care coordination.

A Medicare Advantage plan can offer coordination of your care. This may be especially important if you have one or more chronic conditions, such as diabetes or congestive heart failure. As an example, plans may offer skilled care managers who can help you get the care or services you need at the right time and place. This can include services such as helping you understand and follow your physician’s recommended treatment plan, managing transitions between hospital visits and home, connecting you to resources for food, and helping you get access to necessary prescription drugs and medical equipment. 


Receiving the care you deserve as a dual eligible individual may be challenging. Signing up for a Medicare Advantage plan is one way to potentially help you get the care coordination and additional benefits you need, all in one plan.


Humana is an HMO, PPO and PFFS organization with a Medicare contract. Enrollment in any Humana plan depends on plan renewal.


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