What is Dual Eligible? Why Some People Qualify for Medicare and Medicaid

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There are about 12 million people in the U.S. whose health insurance coverage is provided by both Medicare and Medicaid. Typically, these individuals - known as "dual eligibles" - are seniors with low incomes and people with disabilities.

Both Medicare and Medicaid are government health insurance programs. Medicare, a federal program, is typically for people 65 and older as well as younger people with certain health conditions. Medicaid programs are run by states and territories to cover mostly people with low incomes and disabilities.

Medicare is the primary payer for dually eligible enrollees, who also get financial assistance from their state Medicaid programs. Because dual eligibles have low incomes, it's typically difficult for these enrollees to afford Medicare premiums, cost-sharing, and the expense of services not covered by the Medicare program. Medicaid special programs also supplement care not covered by Medicare.

Here's what you need to know about who qualifies to be covered by both Medicare and Medicaid, as well as how these insurance plans work together for dual eligibles.

What does it mean to be dually eligible for Medicare and Medicaid?

Dually eligible individuals receive full Medicare benefits with partial or full Medicaid benefits because they qualify for both programs. Being dually eligible also means that most of your healthcare costs will be covered, with you paying little or no out-of-pocket costs.

You also are automatically eligible for Extra Help - the Medicare Part D Low Income Subsidy (LIS) - which will cover most of your prescription costs. You'll pay $0 for Part D premiums and deductibles, as well ascopays up to $4.50 for generic and up to $11.20 for brand-name medications in 2024. Without automatic eligibility, Extra Help has income and resource limits.

Who qualifies for dual eligibility?

Only people meeting the eligibility requirements for Medicare and Medicaid are dually eligible. Typically, they are eligible because of their income, as well as their age or condition.

Here's a closer look at the requirements for each program.

Who is eligible for Medicare?

You can qualify for Medicare in these ways:

• By reaching age 65 or older

• By having a disability at any age

• By having permanent kidney failure (end-stage renal disease, or ESRD) or amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease) at any age

Dual eligibles can have either original Medicare or a private Medicare Advantage plan, typically a type known as a Medicare Special Needs Plan.

Who is eligible for Medicaid?

Medicaid eligibility is based on the federal poverty level (FPL), which changes annually. The FPL is the same for the contiguous 48 states and Washington, D.C., but higher in Alaska and Hawaii.

To qualify, you must live in the state where you seek Medicaid coverage and meet the state's income requirements. You also must be a U.S. citizen, lawful permanent resident, or qualified noncitizen.

Low-income families and certain people with disabilities are among the groups that have mandatory eligibility for Medicaid. In 2020, about 73% of dual eligibles received full Medicaid benefits.

Medicare Savings Programs

Most people eligible for full Medicaid qualify for one of the Medicare Savings Programs (MSPs), which are funded by the federal government and run by state Medicaid agencies. That means you also get help paying for Medicare Part A and Part B premiums. You also may qualify for help with Part A and Part B deductibles, coinsurance, and copayments.

To qualify for most MSPs, your income and assets, including savings and investments, will be considered. There are 4 types of MSPs.

Types of Medicare Savings Programs (MSPs)

*Income limits are higher in Alaska and Hawaii. You may qualify in other states even if your income or resources are higher than the limits listed.

** Resources include funds in checking, savings, or retirement accounts, as well as stocks and bonds. States don't count the value of your home, one car, and other household items.

How does dual eligibility work?

If you are dually eligible, Medicare will be the primary payer for your healthcare services. You can have either Original Medicare or a Medicare Advantage plan. Medicaid covers the services and costs not picked up by Medicare.

You still receive full Medicare benefits if you are a partial-benefit dual-eligible enrollee. However, Medicaid would only pay certain out-of-pocket costs, depending on which MSP you have.

What are the benefits of being 'dual eligible'?

Dual eligibles have broad access to healthcare, with very low out-of-pocket expenses. For about 30% of dual eligibles, that comprehensive care is achieved through Dual-Eligible Special Needs Plans (D-SNPs) - which are special Medicare Advantage plans run by states. D-SNPs must coordinate your Medicaid benefits and screen you for other health-related social needs, such as:

• Transportation

• Housing instability

• Food insecurity

One reason this screening is needed, according to advocates, is because lack of transportation was associated with dual eligibles having 85% more hospitalizations and 68% more emergency department visits than people enrolled in either Medicare or Medicaid.

Without a special needs plan, dual eligibles are covered by Medicare for most hospital and medical care, including preventive services such as:

• Exams

• Lab tests

• Screenings

• Vaccines

Original Medicare doesn't cover routine vision, hearing, and dental benefits, but Medicaid provides at least basic vision and hearing, as well as emergency dental services in most states. Medicaid also covers long-term services and supports that aren't benefits under original Medicare and may be lacking under standard Medicare Advantage plans.

If you have Medicare and Medicaid, do you have any gaps in coverage?

Yes. You can have coverage gaps, especially if you only have partial Medicaid benefits. While full Medicaid pays for many services that Medicare doesn't, partial Medicaid is provided through Medical Savings Programs that only cover Medicare premiums but don't cover cost-sharing. For most items and services, Medicare enrollees are typically responsible for 20% of the cost after meeting their Part A and/or Part B deductibles.

Is dual enrollment in Medicare and Medicaid your best option?

Yes. Being dually eligible for Medicare and Medicaid is often the best healthcare option for individuals with low incomes, because you receive the broadest coverage with little or no out-of-pocket costs. That's especially true if you have full Medicaid and Medicare benefits. Even if you only have partial Medicaid benefits, help paying Medicare premiums can make healthcare more affordable for you.

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GoodRx Holdings Inc. published this content on 30 July 2024 and is solely responsible for the information contained therein. Distributed by Public, unedited and unaltered, on 30 July 2024 18:25:20 UTC.