What It Means to Be Dual Eligible for Medicare and Medicaid

How the Programs Work Together

dual eligible for both Medicare and Medicaid
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Although they may sound similar, Medicare and Medicaid are two very different programs. One is intended to provide healthcare to the elderly and/or disabled while the other offers healthcare to the poor.

Millions of Americans are eligible for both programs, 8.3 million according to the Centers for Medicare and Medicaid Services. These beneficiaries are referred to as dual eligible. Understanding how the programs work together will help you make the most of your healthcare experience.

Dual Eligibility Criteria

Medicare eligibility is the same regardless of where you live. It is set by the federal government. To be eligible for Medicare, you need to be 65 years or older or have a qualifying disability. In addition, you must also meet U.S. citizenship or permanent legal residency requirements.

Medicaid eligibility, on the other hand, varies geographically. Although the federal government sets the minimal program requirements, the program itself is run by the individual states. Each state has the option to adjust their eligibility standards.

Medicaid is intended to offer health care to individuals with low income across various categories: children, pregnant women, parents, seniors, and individuals with disabilities. With the passage of the Affordable Care Act, adults without children could also be covered if their state accepted the terms of Medicaid Expansion.

It could be the case that you are eligible for full Medicaid benefits or that you qualify for benefits from one of the Medicare Savings Programs offered through your local Medicaid office. If you are eligible for Medicare and meet criteria for Medicaid or one the following four programs, you may be dual eligible.

  • Qualified Medicare Beneficiary (QMB) Program
  • Specified Low-Income Medicare Beneficiary (SLMB) Program
  • Qualifying Individual (QI) Program
  • Qualified Disabled Working Individual (QDWI) Program

Prescription Drugs Costs

Medicaid requires that you sign up for prescription drug coverage through Medicare, whether that be with a Part D plan or a Medicare Advantage plan with prescription drug benefits, also known as an MA-PD plan. If you partake in the Extra Help program, a low-income subsidy for prescription drug benefits, however, you must enroll in Original Medicare and Part D, not a Medicare Advantage plan. It may be the case that some medications not covered by your Medicare plan will be covered by Medicaid.

Nursing Home Costs

Although Medicare does pay for stays in skilled nursing facilities after a hospitalization, it does not contribute to long-term nursing care. After qualifying hospital stays in 2018, your Part A benefits will pay for all nursing home expenses up to 20 days. For days 21 to 100, you will pay a copayment of $167.50 per day, and for nursing home stays longer than that, you will pay the full amount. 

With millions of seniors affected by dementia and unable to physically care for themselves, nursing home care is a benefit that is necessary for many people. Those who are dual eligible may use Medicaid to pay for long-term nursing home care.

Health Services Not Covered by Medicare

Medicare is not an all-inclusive program. Dental, hearing, and vision screening are not offered nor are dentures, hearing aids, or corrective lenses (contact lenses or eyeglasses) among other healthcare services. If your state Medicaid program offers these services, you may benefit from the added coverage.

Paying for Your Health Care

Generally speaking, Medicare pays first and Medicaid pays second. For those who qualify for the QMB program, Medicaid will pay your Medicare costs, including Part A premiums, Part B premiums, deductibles, coinsurance, and copayments. This is the case even if a Medicare service is not usually covered by Medicaid or if you see a healthcare provider who does not accept Medicaid for payment.

If you are not eligible for QMB, Medicaid can pay less. States do not have to pay if the Medicare service is not also a Medicaid service or if the beneficiary saw a Medicare provider who is not also a Medicaid provider.

A Word from Verywell

Don't assume that because you are on Medicare that you don't qualify for Medicaid. In fact, for millions of seniors, the exact opposite is true. If you are struggling to make ends meet in your retirement years, look to see if you are eligible for Medicaid. This may be the most reasonable way to cut your healthcare costs.

View Article Sources
  • Dual Eligibles. Medicaid.gov. https://www.medicaid.gov/affordable-care-act/dual-eligibles/index.html.
  • Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs. The Centers for Medicare and Medicaid Services website. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf. Published February 2016.
  • Medicare Savings Programs. Medicare.gov. https://www.medicare.gov/your-medicare-costs/help-paying-costs/medicare-savings-program/medicare-savings-programs.html.