Dual Eligibility – Medicare & Medicaid
Dual eligibility refers to individuals who qualify for health coverage from both Medicare and Medicaid. Learn about Medicare, Medicaid, and what it means to be dually eligible.
What is Medicare?
Medicare is a government-run health insurance program, operated on the federal level. It provides health coverage to individuals ages 65 and older, as well as those with certain conditions or qualifying disabilities. Medicare consists of four basic parts: Part A, Part B, Part C, and Part D.
Original Medicare: Part A and Part B
Medicare Part A and B are also called Original Medicare. Part A covers inpatient hospital services and other inpatient care, while Part B covers medical services and routine outpatient care.
Medicare Part C and Part D
Also known as Medicare Advantage, Medicare Part C expands on the coverage of Original Medicare and includes additional covered services which vary from plan to plan.
Medicare Part D covers prescription drugs. Medicare Advantage Prescription Drug (MAPD) plans include drug coverage. Drug coverage can also be purchased as a standalone plan.
What is Medicaid?
Medicaid is also a government-run health insurance program, and it helps certain people with limited resources and income pay their medical costs. Medicaid eligibility rules and coverage vary from state to state. This program does not have an age requirement, because it provides low-cost health insurance for people based on need. The Medicaid program as a whole offers benefits not normally covered by Medicare, such as personal care services and nursing home care.
More than 75 million people are covered by Medicaid, including eligible low-income adults, children, pregnant women, elderly adults, and individuals with disabilities. While Medicaid is a state program, the federal government’s Centers for Medicare & Medicaid Services (CMS) sets quality standards for how it should be run.
You can apply for Medicaid by contacting your State Medical Assistance (Medicaid) office.
What does “Dually Eligible” mean?
Dually eligible individuals are those who qualify for both Medicare and Medicaid. Dual eligibility includes beneficiaries who are:
- Enrolled in Medicare Part A and/or Part B
- Receiving Medicaid benefits
Those who are dually eligible and enrolled in Original Medicare (Part A and Part B) can choose a Medicare Advantage Plan for additional benefits Original Medicare does not cover. Medicare pays first when a person receives Medicare-covered services. Medicaid pays last, after Medicare or any additional health coverage a person may have.
There are several types of Medicare Advantage Plans for qualifying individuals that cost less, cover Part D (prescription drugs), and enable better access to necessary services:
- Special Needs Plans
- Medicare-Medicaid Plans (only available in certain states)
- Program of All-Inclusive Care for the Elderly (PACE) plans
It’s important to know that not all individuals eligible for both Medicare and Medicaid qualify for these plans. There are various levels of Medicaid assistance, which determine the plans that are available to each person. Our advisors can assess the plans available to you based on the specifics of your situation.
Additional Resources
Medicare Savings Programs help individuals who have limited resources and income pay their Medicare costs. These programs help pay for Medicare Part A and B deductibles and copayments, as well as Part B premiums and Part A premiums, if applicable.
To apply for Medicare Savings Programs, you must:
- Have or be eligible for Part A
- Have an income at or below the limits specified by Medicare
- Have limited resources below the limits specified by Medicare
You can apply for Medicare Savings Programs by calling your state Medicaid Agency.
Individuals who enroll in a Medicare prescription drug plan could be eligible for Extra Help from Medicare. This program helps with premiums, deductibles, and copayments for your Part D plan. Social Security estimates that Extra Help is worth around $5,900 per year.
In order to qualify for Extra Help benefits, you must:
- Live in a U.S. state or the District of Columbia
- Have resources limited to $17,220 for an individual or $34,360 for a married couple living together
- Have an annual income limited to $22,590 for an individual or $30,660 for a married couple living together
In many cases, individuals are automatically enrolled in Extra Help. You may also be enrolled automatically if you receive other assistance, such as Medicaid.
If you’re not automatically enrolled in Extra Help, you can apply for it online or call Social Security at 800.772.1213 to request an application or enroll over the phone. You may also apply in person at your local Social Security office.
Once you apply, Social Security will send you a letter to confirm whether you qualify for Extra Help. If you qualify, you can then choose and enroll in a Medicare Part D plan.
Are you dually eligible? Get trusted guidance.
If you or someone you know is dually eligible and needs to enroll in a health plan, our knowledgeable advisors can help you find the right coverage for your needs and budget. We're passionate about helping people just like you, and we genuinely care.
We’ll look into all available savings programs, give you the tools and resources you need to make a confident decision about your health plan, and handle the application and enrollment process―all at no cost. Once your plan enrollment is complete, we’ll continue to provide support and guidance to you for life.