When we need health care, we want simple answers. Can you get hearing aids or new eyeglasses? What about health services to help with daily living?
Here’s what you need to know about who and what’s covered through a dual Medicare and Medicaid plan, such as a Minnesota Senior Health Options (MSHO) plan.
Who is covered under Medicare and Medicaid?
A dual eligible plan, often called a Dual Eligible Special Needs Plan (D-SNP), is for people age 65+ who are enrolled in or eligible for Medicare and Medicaid.
Medicare eligibility
Medicare is a federal health insurance program. You become eligible for Medicare three months before turning 65 years old. People under age 65 with disabilities, end-stage renal disease (ESRD) or amyotrophic lateral sclerosis (ALS) may also be eligible.
Medicaid eligibility
Medicaid is a federal and state program that provides low-income Americans of any age, including 65+, with access to low- or no-cost health coverage. Coverage options and eligibility requirements vary depending on state.
What do Medicare and Medicaid cover?
Medicare and Medicaid, as separate programs, cover different health services. But they can be combined into a single plan to serve people 65 years and older. With a dual plan, you have more health benefits available to you in one plan. This includes hospital, medical, prescription drugs, dental, long-term care, and home and community-based services.
Medicaid and Medicare – simplified in one plan
If you are dual eligible for both Medicare and Medicaid and live in Minnesota, an MSHO plan combines your coverage into one plan with one ID card. All your benefits are together, making it simpler than ever. The health plan handles all the benefits and claims.
MSHO has no monthly premium and low or no cost-sharing for medical and dental services. And your plan covers more than if you just had Medicare or Medicaid alone.
What does an MSHO plan cover?
Here’s general information about common health care needs and what an MSHO plan covers. Review the MSHO plan’s Summary of Benefits or Member Handbook to learn what’s covered. You can find those materials on each MSHO plan’s website. Please note that you may need to meet eligibility criteria to get some benefits.
An MSHO plan covers one Medicare annual wellness visit each year at no cost to you. It’s not a physical exam but rather a conversation with your doctor or care team about these topics:
- Your overall health needs
- Your physical and mental health
- Staying active
- Reducing your risk for falls
Assisted living is housing where people get help with daily activities like getting dressed, meals and housekeeping if they qualify. MSHO covers services provided at assisted living facilities, as well as home care services or personal care assistance. You may qualify for additional care services like chore and companion services or home-delivered meals.
A key feature of a dual eligible plan like MSHO is that members get to work with a Care Coordinator. Care Coordinators are registered nurses or licensed social workers who can help you get the care you need. They’ll support you through all stages of your health care journey.
Some things a Care Coordinator can do:
- Explain how your plan works
- Navigate how your Medicaid and Medicare coverage work together so you don’t have to
- Partner with you to understand your key health goals and collaborate with you to create a person-centered care plan
- Complete assessments with you and help you get services within Medicare and Medicaid, if you’re eligible. This includes services like Elderly Waiver, personal care assistance, chore and companion services, home health care, assisted living, transitional care, nursing home care, and end-of-life care
Plans offer different dental benefits like preventive exams and services, X-rays, fillings, fluoride, dentures and root canals (on some teeth). Some plans cover more like root canals on molars, crowns or additional exams.
Medical benefits in an MSHO plan cover routine eye exams and eyeglasses when medically necessary. The plan pays for contact lenses to correct your vision after cataract surgery or for conditions when eyeglasses won’t work.
Many MSHO plans include a fitness program to keep you active and healthy. This may include a free health club membership or at-home fitness kits. Each plan has its own extra benefits, which may include additional fitness-related tools like an activity tracker or a weight management program.
Medical benefits in an MSHO plan cover routine hearing exams and hearing aids.
MSHO has benefits to help people live on their own and stay in their home. Benefits cover home care services or personal care assistance. You may qualify for additional benefits like chore and companion services or home-delivered meals.
Medicare covers some hospice care services. The Centers for Medicare & Medicaid Services (CMS) has a helpful booklet that explains the benefits.
Dual eligible plans cover outpatient mental or behavioral health services or inpatient care for people who need long-term care.
If you need to live somewhere other than your home because you need ongoing care, an MSHO plan covers short-term skilled nursing facility and long-term nursing home care.
MSHO plans include Part D prescription drug coverage. Your costs depend on your income and whether you live in a long-term care facility. You could pay $0 or a low copay for generic drugs or brand-name drugs.
Occupational, physical or speech therapy are covered benefits after a stroke or accident.
If you have a special health need, an MSHO plan covers rehabilitation services and home medical equipment.
MSHO provides transportation to medical and dental appointments or for other services like lab work. There are general mileage limits to the clinics. Some MSHO plans may provide additional transportation so members can use their plan benefits, like to a fitness club or to health education classes.
MSHO covers urgently needed care and emergency care anywhere in the United States or its territories. The plan also covers an ambulance to get to the emergency room.
MSHO doesn’t cover health care costs you may have when you travel out of the country.
An MSHO plan covers the same vaccines that Medicare Parts A, B and D cover, including the flu, pneumonia, hepatitis B and shingles vaccines.
MSHO plans cover durable medical equipment (DME) or supplies. This may include wheelchairs, nebulizers, crutches, rolling knee walkers, walkers, oxygen equipment and supplies, and more.
Have more MSHO questions?
Our experts are here to help you find the best Medicare plan for the way you live. Learn more about Minnesota Senior Health Options.