60.7 million Americans are Medicare beneficiaries.1 In 2019, more than 12 million Americans are dually eligible for Medicare and Medicaid and are enrolled in both programs.2
Beneficiaries who are eligible for this combination of coverage are sometimes called Medicare 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).
In this guide, we detail how being dual eligible for Medicare and Medicaid can affect your coverage, costs and benefits.
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 low-income individuals and families, children and pregnant women. The best way to find out if you are eligible for Medicaid is to visit your state’s Medicaid website.
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.
The SLMB program helps pay for Medicare Part B premiums.
Like the SLMB, the Qualifying Individual program helps pay for Part B premiums.
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 2020. If your income and resources are slightly higher, you should still apply.
Another type of coverage that may 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:
CHIP is a Medicaid program for children and stands for Children’s Health Insurance Program.
CHIP benefits vary by state, but they generally include EPSDT, or Early and Periodic Screening, Diagnostic and Treatment services. This coverage is designed to ensure children receive proper early detection and related care so that health problems may be averted or diagnosed as early as possible.
CHIP programs in all states must provide well-baby and well-child care, dental coverage, behavioral health care and vaccines.
CHIP serves uninsured children up to age 19 in families that earn too much money to qualify for Medicaid but still have trouble affording care.
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.
There may be Medicare D-SNPs available where you live, though they 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, including the plans that are available and what they may cover.
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1 CMS. Medicare Enrollment Dashboard. Retrieved June 2019, from www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare-Enrollment/Enrollment%20Dashboard.html.
2 Medicaid.gov. Seniors & Medicare and Medicaid Enrollees. Retrieved June 2019, from www.medicaid.gov/medicaid/eligibility/medicaid-enrollees/index.html.
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