What is Medicare Dual Eligible and How Do I Qualify?
Most Americans understand that when they turn 65, Medicare will become their main health insurance plan. However, many Americans are less familiar with another health care program, Medicaid, and what it means if they are eligible for both Medicare and Medicaid. If you are dual eligible, Medicaid may pay for your Medicare out-of-pocket costs and certain medical services that aren’t covered by Medicare.
What is Medicaid?
Like Medicare, Medicaid is a health care coverage program funded by the federal government. It was established to help low-income individuals access health care coverage. Unlike Medicare, however, Medicaid is partially funded by state governments. This means that states have the flexibility to design their Medicaid programs to best meet the needs of their residents, as long as the program meets the minimum federal guidelines. As a result, Medicaid eligibility, services, and cost-sharing (the amount you pay alongside your insurance) policies will vary state-by-state, while the Medicare program is generally consistent across all states.
How do I know if I qualify for Medicaid and Medicare?
Twelve million individuals are currently enrolled in both Medicaid and Medicare.1 These individuals are known as “dual eligible beneficiaries” because they qualify for both programs. As long as you meet the federal qualifications for Medicare eligibility and the state-specific qualifications for Medicaid eligibility, you will qualify as a dual eligible. To qualify for Medicare, individuals generally need to be 65 or older or have a qualifying disability.
There are several levels of assistance an individual can receive as a dual eligible beneficiary. The term “full dual eligible” refers to individuals who are enrolled in Medicare and receive full Medicaid benefits. Individuals who receive assistance from Medicaid to pay for Medicare premiums or cost sharing* are known as “partial dual eligible.”
*Cost sharing is the amount of your health care that you pay out of your own pocket. Typically, this includes deductibles, coinsurance, and copayments.
Levels of Medicaid coverage
Full dual eligible coverage
Qualifications for Medicaid vary by state, but, generally, people who qualify for full dual eligible coverage are recipients of Supplemental Security Income (SSI). The SSI program provides cash assistance to people who are aged, blind, or disabled to help them meet basic food and housing needs. The maximum income provided by the federal government for SSI in 2020 is $783 per month for an individual and $1,175 per month for a couple.2
To qualify for SSI, you must be under a specified income limit. Additionally, your assets must be limited to $2,000 for an individual (or a child) and $3,000 for a couple.3 Qualifying assets typically include things like checking and savings accounts, stocks, real estate (other than your primary residence), and vehicles if you own more than one.
Partial dual eligible coverage
Individuals who are partial dual eligible typically fall into one of the following four Medicare Savings Program (MSP) categories.
Qualified Medicare Beneficiary (QMB) Program
Monthly income limit: $1,084 for an individual, $1,457 for a couple
Helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments
Specified Low-Income Medicare Beneficiary (SLMB) Program
Monthly income limit: $1,296 for an individual, $1,744 for a couple
Helps pay for Part B premiums
Qualifying Individual (QI) Program
Monthly income limit: $1,456 for an individual, $1,960 for a couple
Helps pay for Part B premiums
Qualified Disabled Working Individual (QDWI) Program
Monthly income limit: $4,339 for an individual, $5,833 for a couple
Pays the Part A premium for certain people who have disabilities and are working
Asset limits are determined at any point in time, including but not limited to time of application, eligibility determination, and/or eligibility redetermination.
Federal law defines income and resource standards for full Medicaid and partial dual eligible categories, but states have the option to raise those limits above the Federal minimum standard.
Assets (resources) are different from income and can include things like cash, bank accounts, investments, and property.4
Your state’s Medicaid eligibility office will help you determine any program you are eligible for and if there are additional state-specific programs available.
What does Medicare and Medicaid pay for?
Medicaid is known as the “payer of last resort.” As a result, any health care services that a dual eligible beneficiary receives are paid first by Medicare, and then by Medicaid. For full dual eligible beneficiaries, Medicaid will cover the cost of care of services that Medicare does not cover or only partially covers (as long as the service is also covered by Medicaid). Such services may include but are not limited to:
- Nursing home care
- Care at an intermediate care facility
- Long-term institutional care
- Home health services
- Personal care services (available in some states)
- Other home and community-based services
- Transportation services
- Dental services (available in some states)
- Eye examinations for prescription glasses (available in some states)
The financial assistance provided to partial dual eligible beneficiaries is outlined in the table above.
What are my options for receiving care as a dual eligible?
People who qualify as dual eligible have several options for how their care is delivered, although the number of available options will vary at the state level.
Some Medicare beneficiaries may choose to receive their services through the Original Medicare Program. In this case, they receive the Part A and Part B services directly through a plan administered by the federal government, which pays providers on a fee-for-service (FFS) basis. In this case, Medicaid would “wrap around” Medicare coverage by paying for services not covered by Medicare or by covering premium and cost-sharing payments, depending on whether the beneficiary is a full or partial dual eligible.
Medicare Advantage plans are private insurance health plans that provide all Part A and Part B services. Many also offer prescription drug coverage and other supplemental benefits. Similar to how Medicaid works with Original Medicare, Medicaid wraps around the services provided by the Medicare Advantage plan andserves as a payer of last resort.
Medicaid Managed Care
Some states deliver care to the dual eligible population through Medicaid managed care programs. Others have established Medicaid managed care plans specific to the dual eligible population. Medicaid managed care is similar to Medicare Advantage, in that states contract with private insurance health plans to manage and deliver the care.
In some states, the Medicaid managed care plan is responsible for coordinating the Medicare and Medicaid services and payments. In other states the payments related to Medicaid and Medicare are handled at the state/federal level, and the Medicaid managed care plan is only responsible for coordinating Medicaid services.
Dual Eligible Special Needs Plans (D-SNP)
In some states, dual eligible beneficiaries may have the option of enrolling in a D-SNP. These plans are specially designed to coordinate the care of dual eligible enrollees. Some plans may also be designed to focus on a specific chronic condition, such as chronic heart failure, diabetes, dementia, or End-Stage Renal Disease. These plans often include access to a network of providers who specialize in treating the specified condition. They may also include a prescription drug benefit that is tailored to the condition.
Programs of All-Inclusive Care for the Elderly (PACE)
Similar to D-SNPs, PACE plans provide medical and social services to frail and elderly individuals (most of whom are dual eligible). PACE operates through a “health home”-type model, where an interdisciplinary team of health care physicians and other providers work together to provide coordinated care to the patient. PACE plans also focus on helping enrollees receive care in their homes or in the community, with the goal of avoiding placement in nursing homes or other long-term care institutions.
Which plan should I choose?
Programs and plans may be limited depending on your state and service area. Additional programs may also be available in some locations. To learn more about which type of plan is right for you, see your state’s Medicaid website for contact information.
Content on this site has not been reviewed or endorsed by the Centers for Medicare & Medicaid Services, the United States Government, any state Medicare agency, or any private insurance agency (collectively "Medicare System Providers"). Eligibility.com is a DBA of Clear Link Technologies, LLC and is not affiliated with any Medicare System Providers.