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More than 12 million Americans are dually eligible for Medicare and Medicaid and are enrolled in both programs.1
Beneficiaries who are eligible for this combination of coverage are sometimes called Medicare-Medicaid dual eligible.
If you are dual eligible for Medicare and Medicaid, you may qualify for a special type of Medicare Advantage (Part C) plan called a Medicare Dual-Eligible Special Needs Plan (D-SNP). These plans aren’t available in all locations, however, so be sure to compare local plan options where you live.
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
Medicare and Medicaid are both public health insurance programs. If you are dual eligible, you can have both Medicare and Medicaid coverage at the same time.
Two of the key differences between Medicare vs. Medicaid include:
To be Medicare dual eligible, you have to meet the requirements for Medicare and your state’s Medicaid program.
To be eligible for Medicare, you must:
Generally speaking, Medicaid provides health insurance to individuals and families, children and pregnant women who are eligible based on income specific income thresholds.
One way to find out if you are eligible for Medicaid in your state is to visit your state’s Medicaid website for more information.
If you're eligible for Medicaid and want to find out if you're also eligible for a dual-eligible Medicare Medicaid plan, you can all to speak with a licensed insurance to find out if you're eligible and if any dual-eligible Medicare-Medicaid plans are available where you live.
There are two levels of coverage for beneficiaries who are dual eligible:
A Medicare Savings Program (MSP) is a federally funded program administered within each state that helps lower income people pay for Medicare premiums, deductibles, copayments and coinsurance.
The four Medicare Savings Programs are outlined below.
This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance and copayments.
Eligibility requires:
The SLMB program helps pay for Medicare Part B premiums.
Eligibility requires:
Like the SLMB, the Qualifying Individual program helps pay for Part B premiums.
Eligibility requires:
The QDWI Program helps pay for the Medicare Part A premium for certain people who meet one of the following criteria:
The income and resource limits listed above may increase in 2024. If your income and resources are slightly higher, you should still apply.
Another type of coverage that can be available to dual eligible beneficiaries (depending on where you live) is a Medicare Dual Eligible Special Needs Plan (D-SNP).
A Medicare special needs plan is a certain type of Medicare Advantage plan that is designed for people with specific health conditions or circumstances.
A D-SNP is built for the specific needs of dual eligibles. All Medicare SNPs (including Medicare D-SNPs) provide prescription drug coverage.
For dual eligible beneficiaries, Medicare serves as the primary payer, and Medicaid acts as the secondary payer.
That means Medicare is the first to pay for covered services and items, and then Medicaid will help pay some or all of your remaining costs.
Another Medicare and Medicaid program is PACE, or Programs of All-Inclusive Care for the Elderly.
PACE helps older Medicare beneficiaries to seek health care within their community, in their home and at PACE facilities.
Some of the things that can be covered by PACE include:
PACE is not strictly restricted to Medicare dual eligible beneficiaries. You may be eligible for PACE with only Medicare or only Medicaid (or both).
However, you must meet all of the following conditions:
Extra Help is a federal program that helps pay for out-of-pocket costs related to Medicare prescription drug coverage. Extra Help is also known as the Medicare Part D Low-Income Subsidy (LIS).
The assistance that Medicare Extra Help may provide includes:
You automatically qualify for Extra Help if you are enrolled in Medicaid, Supplemental Security Income or a Medicare Savings Program.
You may still qualify for Extra Help if you are not enrolled in any of those programs but still have income and assets below a certain limit.
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Medicare D-SNPs aren’t as widely available as other types of Medicare Advantage plans.
A licensed insurance agent can help you explore your Medicare Advantage plan options. Compare the plans that are available and find out what they may cover and whether you’re eligible.
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.
Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.
Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.
Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.
A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.
If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.
1 Centers for Medicare & Medicaid Services (CMS). March 2023. People Dually Eligible for Medicare and Medicaid. https://www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare-medicaid-coordination-office/downloads/mmco_factsheet.pdf.
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