Who Qualifies for a Dual Eligible Medicare Plan

Written by: Vanessa Jerusalimiec (*Amsive Digital)  |  Reviewed by: Shelley Wyant  |  *MHP partners with Amsive Digital on news content

Dual Eligible Medicare Plan

If you’re a low-income adult, you may qualify for both Medicare and Medicaid coverage. This is called dual eligible. When you’re dual eligible, you receive coverage from the federal Medicare health insurance program as well as the state-run Medicaid assistance program.

What Does Dual Eligibility Mean?

If you’re a dual eligible beneficiary, you can enroll in both Medicare and Medicaid to cover most or all of your health care costs. You can enroll in Original Medicare or a Medicare Advantage Plan. If you have Original Medicare, you’ll also enroll in Medicare Part D to cover the cost of prescription medications. Medicaid will cover any remaining costs and may even help cover the cost of Medicare premiums, deductibles, and copayments.

Who Qualifies for a Dual Eligible Medicare Medicaid Plan?

You are considered dual eligible if you qualify for both Medicare and Medicaid coverage. Medicare eligibility is usually based on age. You’re eligible for Medicare if:

  • You’re over 65
  • You’re under 65 and have a permanent health condition such as ESRD
  • You’re a U.S. citizen or permanent resident

Medicaid eligibility is based on income and assets. You may qualify for coverage depending on your family size, household income, age, disability, and other factors. If your income is low, you may qualify for partial coverage of some Medicare costs, or full coverage of most Medicare costs. If you’re approved for full Medicaid coverage you may also qualify for Extra Help, a program that helps you cover Medicare Part D premiums, deductibles, and copayments.

How Many Americans Are Dual Eligible?

In 2018, 12.2 million Americans were enrolled in both Medicare and Medicaid. This is approximately 18% of all Medicare beneficiaries. Dual eligible beneficiaries use Medicare to cover primary and preventive care as well as pay for prescription medications. Medicaid may cover long-term care, additional services like dental, vision, and transportation, and some Medicare premiums and costs.

Who Pays First if You’re Dual Eligible?

If you have both Medicare and Medicaid coverage, most of your health care costs will be covered. Medicare pays first, and then Medicaid covers the rest. Depending on the service, you may have a small copayment at the end, but most of your health care costs are covered. When you fill prescription Medications, Medicare pays first, then Medicaid pays next. Finally, Extra Help will cover most or all of the remaining costs.

If you access a service that’s covered by Medicaid but not covered by Medicare, then Medicaid pays first, and you’ll pay any remaining cost.

What’s Covered for Dual Eligible Beneficiaries?

Medicare coverage includes hospital and medical coverage, while Part D plans provide prescription drug coverage. Medicaid covers the remaining cost of these benefits, as well as covering some additional services that can include:

  • A yearly health exam
  • Skilled nursing facility care
  • Personal care
  • Respite care
  • Home-based services
  • Dental, vision, and hearing services
  • X-rays and lab tests
  • Medical supplies
  • Physical therapy
  • Podiatry or foot care

If you’re enrolled in Medicare and Medicaid, you’ll benefit from greater health care coverage and lower out-of-pocket costs.

Medicare Savings Programs

You may also qualify for help paying your Medicare Part A and Part B premiums. Medicare Savings Programs may pay for premiums, deductibles, coinsurance, and copayments. You can enroll in a Qualified Medicare beneficiary Program if your individual monthly income is under $1,094. If you’re a married couple, the monthly income limit to qualify is $1,472.

How Do I Know If I’m Dual Eligible?

You can find out if you’re dual eligible for Medicare and Medicaid by contacting your state’s Medicaid office or your State Health Insurance Assistance Program (SHIP). Eligibility and benefits vary widely from state to state so find out more about Medicare and Medicaid guidelines in your area when you apply for health care coverage.