Medicare is the federal health insurance program in the United States for people age 65 and older. Medicaid is a joint federal and state program to help people with limited resources or income pay for medical costs.
According to Health Affairs, about 9.2 million people, representing about 16 percent of Medicare enrollees and about 15 percent of Medicaid enrollees, are enrolled in both Medicare and Medicaid.
Keep reading to learn more about dual eligibility, benefits, and state-by-state differences.
The terms Medicaid and Medicare are often confused since they are both government healthcare programs. They even sound extremely similar, but they are actually very different.
Medicare is a government-funded medical insurance option that many older Americans use as their primary health insurance. It also covers people with certain disabilities and health conditions. Medicare is not free coverage — you’ll still pay deductibles, premiums, and copays for medical services.
Medicaid is a program that combines the efforts of the U.S. state and federal governments to assist households in low-income groups with healthcare expenses. These may include major hospitalizations and treatments as well as routine medical care. This care is often provided at low or no cost, depending on your income. Medicaid also offers benefits not typically covered by Medicare.
If you’re eligible for both Medicare and Medicaid, you’re considered a dual eligible beneficiary. Dual eligibility is typically determined by your age, any disabilities, and income.
Who pays first if you have dual eligibility?
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
What are the state-by-state differences?
Benefits for dual eligible beneficiaries candiffer 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.
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).
Below is table summarizing the benefits and eligibility criteria for each of the different MSPs in 2021:
|Qualified Disabled Working Individual (QDWI) program||pays the Part A premium for certain beneficiaries who are working and have certain disabilities||individual monthly income of $4,379 or less, individual resources limit of $4,000;|
married couple monthly income of $5,892 or less,
married couple resources limit of $6,000
|Qualifying Individual (QI) program||assists in the payment of Part B premiums||individual monthly income of $1,469 or less, individual resources limit of $7,970; married couple monthly income of $1,980 or less, married couple resources limit of $11,960|
|Qualified Medicare Beneficiary (QMB) program||assists in the payment of deductibles, premiums, coinsurance, and copayments for Part A, Part B, or both||individual monthly income of $1,094 or less, individual resources limit of $7,970; married couple monthly income of $1,472 or less, married couple resources limit of $11,960|
|Specified Low-Income Medicare Beneficiary (SLMB) program||assists in the payment of Part B premiums||individual monthly income of $1,308 or less, individual resources limit of $7,970; married couple monthly income of $1,762 or less, married couple resources limit of $11,960|
In addition to the Medicare savings programs, you also may be eligible for some of the following needs-based programs through Medicare:
- PACE (Program of All-inclusive Care for the Elderly): a Medicare-Medicaid joint program that provides medical and social services for people with significant needs who want to continue living at home
- Medicare’s Extra Help program: can help those with low incomes get the prescription drugs they need at reduced or no cost
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 an MSP
If you’re a dual eligibility beneficiary, it’s likely that most of your healthcare costs are covered.