For Case Managers & Navigators

The Helper Landscape

Helping clients choose and navigate coverage requires understanding the distinct roles and limitations of each profession. Here's how the major roles differ:

Screening for Programs: The Eligibility Roadmap

Helping a client identify which programs they may qualify for is often the first step. Use these key criteria to guide your screening:

Age

• Medicare: Generally age 65+, or younger with disability or ESRD.
• Medicaid: No age limit; working-age adults, seniors, children, and pregnant women may all qualify (varies by state).
• CHIP: Children under 19 (age limits vary by state).
• ACA Marketplace: Anyone not eligible for employer or public coverage.

Income & Resources

Every program has income limits set annually and varying by state. Gather household income (not wages alone) and household size, then direct clients to:

• healthcare.gov (Marketplace & Medicaid screening)
• benefits.gov (comprehensive screening)
• Your state Medicaid agency (find yours here)

Medicare Savings Programs, Extra Help, and PACE

Three programs often missed during initial screening:

• Medicare Savings Programs (QMB, SLMB, QI): Low-income Medicare beneficiaries; programs pay Part A/B premiums and cost-sharing. Medicaid-run, so apply through your state.
• Extra Help (Low-Income Subsidy, LIS): Helps with Part D premiums and cost-sharing for prescription drugs. Apply via Social Security or at healthcare.gov.
• PACE (Program of All-Inclusive Care for the Elderly): Integrated Medicare/Medicaid for frail seniors 55+. Check Medicare.gov for programs in your area.

Bookmark: Link clients to Getting Help Paying for a full overview of cost-assistance programs.

Dual-Eligible Coordination: Medicare & Medicaid Together

Roughly 12 million people have both Medicare and Medicaid. Helping them avoid coverage gaps and duplicate costs is critical.

The Landscape

• Medicare is primary for all Medicare-covered services. Medicaid pays cost-sharing (copays, deductibles) if the beneficiary qualifies for a Medicare Savings Program.
• Medicaid-only services (long-term care, NEMT, vision, dental beyond routine) remain available if the person retains Medicaid eligibility.
• D-SNPs (Dual-eligible Special Needs Plans): Medicare Advantage plans designed for dual-eligible beneficiaries. They cover basic Medicare benefits plus some Medicaid add-ons (e.g., dental, vision, hearing).

Common Pitfalls

• Disenrollment from Medicaid after gaining Medicare eligibility — losing Medicaid coverage for long-term care, non-emergency transport, or supplemental dental/vision.
• Choosing a Medicare plan without checking Medicaid coordination rules in the state.
• Missing annual redetermination deadlines for Medicaid (vary by state, especially important post-PHE continuous-enrollment unwinding).

Help clients understand: A D-SNP may simplify enrollment, but it does not automatically preserve Medicaid. They must reapply for Medicaid separately and meet all eligibility requirements.

Transitions of Care: Discharge Planning & Continuity

Hospital discharge, moving to a nursing home, or starting home health services all require coverage verification and planning.

Your Checklist

1. Verify active coverage. Before discharge, confirm the patient's Medicare/Medicaid is current and which plan is enrolled in. Call the plan to check network status for the recommended follow-up provider.
2. Check prior authorization. Some post-acute services (home health, skilled nursing, DME) require pre-authorization from the plan. Many require it within 24–48 hours of discharge.
3. Confirm DME coverage. Durable medical equipment (walkers, oxygen, hospital beds, wheelchairs) has specific coverage rules. Medicare covers some; Medicaid rules vary by state. Verify before the patient goes home.
4. Non-emergency medical transportation (NEMT). Medicaid in most states covers NEMT for medical appointments. Medicare does not. Ensure the patient knows how to arrange it.
5. Follow-up appointment scheduling. Confirm the discharge provider accepts the patient's plan. If not in-network, clarify whether out-of-network costs apply (especially in Medicare Advantage).

Special Scenarios

• Transfer between settings: Nursing home to home, hospital to home health, etc. Ensure the next provider is aware of coverage and can bill correctly.
• Coverage changes during hospitalization: Rare, but possible during long hospitalizations (e.g., Medicaid disenrollment after a redetermination decision). Check with the plan before discharge.

Appeals & Advocacy Support

Clients have the right to appeal coverage denials, claim disputes, and billing issues. As an advocate, you can help them understand the process and meet deadlines.

Your Role as an Authorized Representative

• File an Appointment of Representative form (CMS-1696 for Medicare, state-specific for Medicaid) to act as a formal advocate on the client's behalf.
• Request medical records, billing statements, and appeal decisions on behalf of the client.
• Attend appeals hearings or administrative conferences.

Appeal Levels & Deadlines

Processes vary by program and plan type. Generally:

• Medicare: Beneficiary or representative must request an appeal within 120 calendar days of receiving the denial notice. Levels: redetermination → reconsideration → fair hearing → appeals council → federal court.
• Medicaid: Appeals timelines vary significantly by state. Some allow 10–30 days; check your state's rules. Find your state agency here.
• ACA Marketplace: Customers can request an appeal to the issuer, then to state insurance commissioners. Timelines vary.

See Your Rights for a full overview of appeal and grievance processes.

Enrollment Periods & Renewals

Missing an enrollment deadline or falling through the cracks during a renewal can leave clients uninsured or with gaps in coverage.

Key Windows to Track

• Medicare Initial Enrollment Period (IEP): 3 months before to 3 months after the month they turn 65 (65 months total). Late enrollment penalties apply if missed.
• Medicare Annual Open Enrollment: October 15 — December 7 each year. Changes take effect January 1.
• Medicaid: Year-round enrollment in most states. Continuous enrollment unwinding (post-COVID) has ended in most states; redeterminations are ongoing. Verify renewal deadlines with your state agency.
• ACA Marketplace Open Enrollment: November 1 — January 15 (dates vary by year). Special Enrollment Periods open for qualifying events (job loss, marriage, birth, loss of coverage, income change, address change). 60 days from the triggering event.

Redetermination & Renewal Outreach

• Track client renewal/redetermination dates. Set reminders 60 days before expiration.
• Verify contact information on file. Notices go to the address on file; if it's wrong, the client may miss deadlines.
• Help clients renew online, by phone, or by mail—whatever works for them.
• For Medicaid, confirm the renewal was processed and new eligibility notice was received.

See Enrollment & Deadlines for a detailed calendar and deadline tracker.

Trusted Tools & National Resources

Equip yourself and your clients with reliable, official tools:

Boundaries: Staying in Scope

Covering the Gaps: What Else to Know

For deeper dives into specific topics, explore MediPrimer's other resources:

• Coverage Basics — How Medicare, Medicaid, and the ACA Marketplace work at a high level.
• Plan Types — Differences between Original Medicare, Medicare Advantage, Medigap, Medicaid plans, and ACA Marketplace plans.
• How Do I? — Answers to common procedural questions (enroll, switch plans, appeal, report changes).
• Caregivers & Family — For clients who have a family member or spouse helping them navigate.
• Glossary — Definitions of acronyms and common terms (CNI, HAO, QMB, etc.).

Verify details with official sources. Program rules, income limits, plan features, and deadlines change every year. Always check the official program website (Medicare.gov, your state Medicaid agency, HealthCare.gov) before advising a client. MediPrimer is an independent educational resource and is not affiliated with CMS, Medicare, Medicaid, any state agency, or any health insurance company. Nothing on this page is legal, medical, or financial advice, and no recommendation is made for a specific plan or program.