Medicare is the federal health insurance program in the United States for people age 65 and older. It also covers people with certain disabilities and health conditions.
Medicaid is a joint federal and state program to help people with limited resources or income pay medical costs. It offers benefits typically not covered by Medicare.
If you’re eligible for both Medicare and Medicaid, you’re a dual eligible beneficiary.
Keep reading to learn more about dual eligibility, including qualifications, benefits, and state-by-state differences.
Typically a reflection of age, disability, or income, a dual eligibility classification is based on you being either:
- enrolled in Medicare and receiving full Medicaid benefits
- enrolled in Medicare and receiving assistance with Medicare premiums
You’re also considered a dual eligible beneficiary if you’re enrolled in Medicare Part A or Part B and receiving cost-sharing through a Medicare Savings Program (MSP).
Medicare Savings Programs
- Qualified Medicare Beneficiary (QMB) Program: assists in the payment of deductibles, premiums, coinsurance, and copayments for Part A, Part B, or both.
- Specified Low-Income Medicare Beneficiary (SLMB) Program: assists in the payment of Part B premiums
- Qualifying Individual (QI) Program: assists in the payment of Part B premiums
- Qualified Disabled Working Individual (QDWI) Program: pays the Part A premium for certain beneficiaries working with disabilities
Dual eligibility beneficiaries aren’t limited to original Medicare.
If you have dual eligibility, you can also get your Medicare coverage through a Medicare Advantage Plan.
Dual eligible beneficiaries are automatically enrolled in Medicare Part D prescription drug plan.
You may also get extra help for your Part D coverage. Extra help is a Medicare program to help pay Part D prescription drug program costs for people with limited resources or income.
In most cases, Medicaid will cover drugs not covered by Medicare Part D.
Since Medicaid is generally the payer of last resort, for dual eligible beneficiaries, Medicare pays covered medical services first.
If you have other coverage, such as employer group health plans or Medicare supplement plans (Medigap), that coverage will pay first and Medicaid last.
Medicaid may cover healthcare costs that Medicare may not cover, or only partially covers, such as:
- home-based services
- personal care
- nursing home care
Benefits for dual eligible beneficiaries can differ based on your state of residence. Differences by state may include:
- Medicaid offered through Medicaid managed care plans
- fee-for-service Medicaid coverage
- plans that include all Medicare and Medicaid benefits
Income and resource standards are defined by federal law for full Medicaid and the Medicare Savings Programs. At their discretion, states can effectively raise the federally mandated limits.
Dual eligibility for Medicare and Medicaid means that you’re enrolled in Medicare and either:
- receiving full Medicaid benefits
- receiving assistance with Medicare premiums
- receiving cost-sharing through a Medicare Savings Program (MSP)
If you’re a dual eligibility beneficiary, it’s likely that most of your healthcare costs are covered.
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