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30/07/2024 | Press release | Distributed by Public on 31/07/2024 01:25

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

Key takeaways:

  • Dual eligibles are people enrolled in both Medicare and Medicaid. Generally, you qualify for both because of your age, disability or condition, and/or income. Medicare is the primary coverage, and Medicaid wraps around to supplement services and provide financial assistance.

  • While dual eligibles receive full Medicare benefits, their income and assets determine their eligibility for full or partial Medicaid benefits.

  • Some dual eligibles are covered by Medicare-Medicaid combination plans that provide comprehensive coverage, such as the Program of All-Inclusive Care for the Elderly (PACE) and Dual-Eligible Special Needs Plans (D-SNP).

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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.

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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:

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)

Program name What it pays for Monthly income limit for 2024* Resource limit for 2024**
Qualified Medicare Beneficiary (QMB) Program Part A premiums, as well as Part B premiums, deductibles, coinsurance, and copays for Medicare-covered services and items; you also get Extra Help for prescriptions Individual: $1,275 Married couple: $1,724 Individual: $9,430 Married couple: $14,130
Specified Low-Income Medicare Beneficiary (SLMB) Program Part B premiums, but you must have Parts A and B to qualify; you also get Extra Help Individual: $1,526 Married couple: $2,064
Qualifying Individual (QI) Program Part B premiums, but you must have Parts A and B to qualify; you also get Extra Help Individual: $1,715 Married couple: $2,320
Qualified Disabled & Working Individual (QDWI) Program Part A premiums Individual: $5,105 Married couple: $6,899 Individual: $4,000 Married couple: $6,000

*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.

Frequently asked questions

Do dual eligibles qualify for the PACE program?
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The Program for All-Inclusive Care for the Elderly, known as PACE, provides comprehensive medical care and home services to older people living in PACE service areas. About 90% of PACE participants are dually eligible for Medicare and Medicaid.

Does partial Extra Help still exist?
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Extra Help, also known as the Medicare Part D Low Income Subsidy (LIS), assists Medicare enrollees with their prescription costs. The partial subsidy was eliminated in 2024. Now, people with Extra Help will pay $0 for Part D premiums and deductibles, as well as reduced copays for their generic and brand-name medications. Dual eligibles, people who receive Supplemental Security Income (SSI), and those enrolled in a Medicare Savings Program are automatically enrolled in Extra Help. Other people who believe they qualify can apply online with the U.S. Social Security Administration or by calling Social Security at 800-772-1213.

Why is dual-eligibility status so important?
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Dual eligibles are important enrollees in the Medicare and Medicaid populations because they have low incomes and a high occurrence of chronic conditions and disabilities. They typically have significant care needs and disproportionately high healthcare expenses. They need this coverage because many have no alternative insurance. According to a 2023 KFF profile of Medicare-Medicaid enrollees, dual eligibles account for 17% of people in original Medicare and 14% of people with Medicaid. But 33% of original Medicare spending and 32% of Medicaid spending goes to the care of dual eligibles.

The bottom line

Medicare-Medicaid enrollees known as "dual eligibles" are typically people with low incomes, modest savings, and chronic health conditions. They have comprehensive health coverage, with Medicare as their primary health insurance, along with Medicaid to ensure that they have access to the full range of benefits not covered by Medicare, at little to no cost.

For example, nursing home care, vision care, and transportation to medical appointments are just a few services that original Medicare doesn't cover, but Medicaid does. However, not everyone receives full Medicaid benefits. If you are dually eligible and covered by a Medicare Savings Program, you may get financial help with Medicare Part A and/or Part B premiums, as well as Part B deductibles, coinsurance, and copays.

People with dual eligibility who have full Medicaid benefits are automatically qualified for Medicare's Extra Help program, which pays their Medicare Part D prescription drug plan premiums and deductibles while reducing prescription copays to less than $12 in 2024.

References

Centers for Medicare & Medicaid Services. (2024). Medicare Learning Network fact sheet.

Costanza, K. (2024). Those eligible for Medicare and Medicaid face twin challenge. National Conference of State Legislatures.

View All References (24)
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Gershon, R., et al. (2024). Dual Eligible Special Needs Plans (D-SNPs): What advocates need to know. Justice in Aging.

Healthcare.gov. (n.d.). Coverage for lawfully present immigrants. Centers for Medicare & Medicaid Services.

Healthcare.gov. (n.d.). Federal poverty level (FPL). Centers for Medicare & Medicaid Services.

Humana. (2023). How to qualify for both Medicare and Medicaid.

Medicaid.gov. (n.d.). List of Medicaid eligibility groups. Centers for Medicare & Medicaid Services.

Medicaid.gov. (n.d.). Programs of All-Inclusive Care for the Elderly benefits. Centers for Medicare & Medicaid Services.

Medicaid.gov. (n.d.). Seniors & Medicare and Medicaid enrollees. Centers for Medicare & Medicaid Services.

Medicaid.gov. (n.d.). Where can people get help with Medicaid & CHIP? Centers for Medicare & Medicaid Services.

Medicare Payment Advisory Commission, et al. (2024). Beneficiaries dually eligible for Medicare and Medicaid.

Medicare.gov. (n.d.). Costs. Centers for Medicare & Medicaid Services.

Medicare.gov. (n.d.). End-stage renal disease (ESRD). Centers for Medicare & Medicaid Services.

Medicare.gov. (n.d.). Help with drug costs. Centers for Medicare & Medicaid Services.

Medicare.gov. (n.d.). Medicare Savings Programs. Centers for Medicare & Medicaid Services.

Medicare.gov. (n.d.). PACE. Centers for Medicare & Medicaid Services.

Medicare.gov. (n.d.). Preventive & screening services. Centers for Medicare & Medicaid Services.

Medicare.gov. (n.d.). Save on your Medicare drug costs with Extra Help. Centers for Medicare & Medicaid Services.

National Council on Aging. (2024). Understanding Medicare's Part D Low Income Subsidy (LIS/Extra Help).

National Pace Association. (n.d.). Eligibility requirements.

Office of the Assistant Secretary for Planning and Evaluation. (2024). Poverty guidelines. U.S. Department of Health and Human Services.

Peña, M. T., et al. (2023). A profile of Medicare-Medicaid enrollees (dual eligibles). KFF.

Regeneron Pharmaceuticals, Inc. (2023). Understanding dual-eligible health benefits: An overview for patients who may qualify for both Medicare and Medicaid.

Schwarz, C. (2024). People can get even more Extra Help in 2024. Medicare Rights Center.

Social Security Administration. (n.d.). Apply for Medicare Part D Extra Help program.

U.S. Department of Health and Human Services. (2022). Does Medicaid cover dental care?

GoodRx Health has strict sourcing policies and relies on primary sources such as medical organizations, governmental agencies, academic institutions, and peer-reviewed scientific journals. Learn more about how we ensure our content is accurate, thorough, and unbiased by reading our editorial guidelines.

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