What is “Dual Eligible” for Medicare and Medicaid?

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Sometimes, the cost of medical care can keep people from seeking out the services they need, especially in situations where it is difficult enough to keep the lights on or buy groceries.

In these situations, government health insurance programs can help with or even cover the cost of necessary exams, procedures or health screenings to ensure that income does not keep people from being healthy. This is where Medicare and Medicaid come in to provide benefits.

Generally, Medicare is reserved for people close to retirement age or with life-altering disabilities to offer insurance coverage. Medicaid is known for helping low-income families and people with the cost of healthcare regardless of age.

In some cases, you may qualify for both programs — something known as being “dual eligible.”

What is Dual Eligibility?

Dual eligibility is the term used to explain that you qualify for both Medicare and Medicaid benefits.

This usually occurs in situations where you already qualify for Medicare but because of low income, cannot afford the remaining costs such as deductibles or your portion of the medical bills. If you are dually eligible for both programs, most of your health care expenses will likely be covered, leaving you with a smaller (or no) bill to foot for the care you need.

About 9 million people in the United States have dual eligibility for Medicare and Medicaid.

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Understanding the Difference Between Medicare and Medicaid

It is possible to use both Medicare and Medicaid to help with the cost of medical procedures and exams, but you should know how the two programs are different.

Medicare offers health insurance benefits to people who are at least 65-years-old or for people who have disabilities or kidney failure. This kind of insurance is provided by the U.S. federal government and consists of multiple parts that cover different medical needs, such as hospital insurance, medical insurance (for use at doctors’ offices) and prescription medications.

Medicare also offers another option — Medicare Advantage Plan — that allows people to receive their Medicare benefits through a private insurance company. This avenue allows beneficiaries to customize their health insurance needs.

Medicaid is a state program that helps low-income individuals and families with the costs of healthcare. This is different from Medicare because you do not have to have a disability or be over the age of 65 to receive health insurance benefits.

Medicaid’s goal is to help people who truly cannot afford the cost of health services because of their income level regardless of age. People who qualify for Medicaid may get assistance paying for premiums, deductibles, coinsurance, copayments, and prescription drugs. And in some cases, Medicaid covers things that Medicare will not, such as the cost of nursing home stays or personal care attendants.

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How Do I Get Dual Eligibility?

To become dual eligible for both Medicare and Medicaid, you will first need to be enrolled in Medicare. You are not required to be enrolled in every part of Original Medicare or a Medicare Advantage plan, but signing up for Medicare benefits beyond Part A hospital insurance is ok to do.

While Medicare is a federal program with one set of requirements, Medicaid is a state-led program that varies from state to state. This means that each state has its own rules for eligibility. While it is hard to give a general guideline to determine your eligibility, most people qualify for Medicaid benefits if they live at or below their state’s poverty level. The best way to determine if you qualify for dual eligibility is to contact your state Medicaid agency to find out what the income requirements are.

While Medicaid eligibility is generally determined by your income, there are some cases where you can surpass the qualifying limit but still receive help. This is called the Medicaid spend down and allows you to use Medicaid benefits if you become “medically needy.” This means that the cost of your healthcare largely impacts your income, or “spends down” the amount of income that you have available. Not all states have medically needy programs, and those that do may limit assistance to people with disabilities, the elderly, children, or pregnant women or women undergoing fertility treatments.

Unlike Medicare enrollment, which can happen automatically when you reach age 65, there is no automatic sign-up for Medicaid. This means you will have to contact your state government to be enrolled. And, because Medicaid eligibility is determined by your income, any changes such as an increase could impact your benefits in the future.

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Dual Eligibility Programs

If you are dually eligible for Medicare and Medicaid, there are some differences in how you will receive your healthcare benefits. In terms of Medicare, your health coverage will be through Original Medicare or a Medicare Advantage plan of your choice. If you are enrolled in Part D prescription drug benefits through Medicare, you will be automatically enrolled in the Extra Help program to help with medication costs. In some cases, Medicaid will additionally cover some prescription drugs that Medicare does not.

There are different levels of Medicaid that can help with the overwhelming costs of healthcare. These include:

  • Qualified Medicare Beneficiary Program (QMB): Helps with the cost of Medicare Part A and Part B premiums, as well as deductibles, copayments and coinsurance.
  • Specified Low-income Medicare Beneficiary Program (SLMB): Assists with Part B premiums
  • Qualifying Individual Program (QI): Helps with the cost of Part B premiums
  • Qualified Disabled Working Individual Program (QDWI): Assists with Part A premiums for some people who have a disability but work.

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How Medicaid and Medicare Work Together

Medicaid works to help alleviate costs after Medicare has paid its portion. This means that Medicaid never pays first for your healthcare costs, especially if your Medicare benefits would cover some or all of a particular need or service.  After Medicare pays for your doctors’ visits, surgeries or procedures, any other kinds of health insurance will then kick in. This means if you have an employee or union health package, it will pay second, followed by additional coverage you might have such as a Medigap plan. Medicaid comes in at the end of the process, picking up costs after all other kinds of insurance have paid their portion.

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