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 for medical costs. It also offers benefits not typically covered by Medicare.
Keep reading to learn more about dual eligibility, benefits, and state-by-state differences.
If you’re eligible for both Medicare and Medicaid, you’re considered a dual eligible beneficiary. Next, we’ll go over some frequently asked questions about how dual eligibility works.
How can you get both Medicaid and Medicare?
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
What are Medicare savings programs?
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 2020:
|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 $4,339 or less, individual resources limit of $4,000;|
married couple monthly income of $5,833 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 $1,456 or less, individual resources limit of $7,860; married couple monthly income of $1,960 or less, married couple resources limit of $11,800|
|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 $1,084 or less, individual resources limit of $7,860; married couple monthly income of $1,457 or less, married couple resources limit of $11,800|
|Specified Low-Income Medicare Beneficiary (SLMB) program||assists in the payment of Part B premiums||individual monthly income of $1,296 or less, individual resources limit of $7,860; married couple monthly income of $1,744 or less, married couple resources limit of $11,800|
Dual eligibility beneficiaries aren’t limited to original Medicare. Let’s take a look at the other plan options that are available to you.
Medicare Part C
If you have dual eligibility, you can also get your Medicare coverage through a Medicare Advantage plan (Part C). This option offers the same Part A and Part B coverage as original Medicare, plus additional coverage for prescription drugs, dental, vision, and more.
Medicare Part D
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:
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.
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.