How To Qualify for Both Medicare and Medicaid
To qualify for both Medicare and Medicaid, you must meet specific eligibility criteria for each program. These criteria can vary depending on your age, income, disability status, and other factors.
Individuals who qualify for both Medicare and Medicaid are “dual eligible” for both plans, offering many benefits beyond the individual programs. This is possible because Medicare and Medicaid are administered separately.
Medicare is administered by the federal government and is accessible to virtually any permanent resident of the US over the age of 65. In contrast, Medicaid is administered individually by each state, with the eligibility requirements (generally based on income) shifting depending on the needs of that region. Therefore, one’s ability to become dual-eligible is affected not just by age and income level but also location.
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Can You Use Medicare and Medicaid At The Same Time?
Yes, it is possible to use Medicare and Medicaid simultaneously. In fact, it’s common for people to use Medicare and Medicaid simultaneously. Dual enrollees comprise 17% of Medicare recipients and 14% of Medicaid recipients. Altogether, joint enrollees add up to 12.5 million people.
Dual eligibles are categorized based on whether they receive full or partial Medicaid benefits.
Full-benefit Medicare-Medicaid enrollees receive full Medicaid benefits. As a result, Medicaid pays their Medicare premiums and, often, any other out-of-pocket costs.
In contrast, partial-benefit Medicare-Medicaid enrollees don’t get full Medicaid benefits. But Medicaid helps by paying Medicare premiums and, often, cost sharing.
Many people enjoy dual coverage because it helps them save money on healthcare costs and provides additional benefits. Dual coverage also works with other government-subsidized healthcare programs outside of Original Medicare, such as Medicare Advantage.
How Does Dual Eligibility Work?
Using both coverages together is relatively simple. Medicaid works much like a Medicare Supplement plan by paying some out-of-pocket expenses that Medicare does not. This is a boon to low-income individuals, as Medicare Supplement Plans generally are offered by private insurers and paid for separately by the recipient.
Who Is Eligible?
Medicaid and Medicare are two different government programs managed at the state and national levels. Perhaps due to confusion, many people who could qualify are not enrolled.
Medicaid is a state-managed program that helps cover low-income individuals of any age. This coverage gives free or reduced-price healthcare in your state of residence or where you live. Because Medicaid is state-run, the income limits (the most you can make and still get Medicaid) and benefits vary from state to state.
In contrast, the U.S. government’s Medicare helps pay for healthcare to anyone over age 65 (or younger with certain critical conditions such as End Stage Renal Disease), regardless of income. The federal government sets qualifications, benefits, and costs, and they are more or less universal despite where you specifically live.
Therefore, if you make less than the income threshold for Medicaid in your state of residence and are over 65 or have a lifelong disability, you can gain dual eligibility.
What Coverage Is Available With Dual Eligibility?
Dual-eligible individuals benefit from both forms of insurance. However, you’ll mainly use one insurance, Medicare, over the other.
The reason for this phenomenon is that Medicare has significantly more choices when it comes to providers. Generally, Medicaid offers a network of providers within a state or county. In contrast, if you have Original Medicare, you can use any U.S. medical facility accepting Medicare. Further, Medicare is better funded than Medicaid, owing to it being federally funded. With more funds available to provide services to enrollees, the more accessible it becomes.
However, Medicaid may cover additional services beyond those provided under Medicare. This might include nursing facility care beyond Medicare’s 100-day limit, eyeglasses, hearing aids, and prescription drugs. What’s more, those services are often 100% free of charge to those who qualify. Further, Medicaid will cover out-of-pocket costs associated with Original Medicare, such as premiums, deductibles, copayments, coinsurance, and extra help for drug costs.
The Payer of Last Resort
Because Dual Eligible people receive services from Medicare first, with Medicaid paying the remaining costs Medicare does not cover, Medicaid is known as “the payer of last resort.”
For example, consider a situation where a dual-eligible individual breaks their leg. Medicare will pay for the hospital surgery to fix the injury and some of the follow-up appointments. However, there would be several out-of-pocket costs not covered by Medicare, such as the cost of prescription drugs and medical equipment. Further, due to the 80% coinsurance agreement, 20% of the total cost of treatment would fall on the beneficiary. Medicaid would then kick in, covering most or all of the remaining costs.
Further, the payer of last resort will pay for treatment and services that Medicare will only cover partially. For example, Medicare only pays for up to 100 days of skilled medical care in a facility. In contrast, Medicaid will pay for inpatient, long-term care almost indefinitely. Keep in mind that it will only do so if the facility is Medicaid certified.
Some examples of fully covered benefits available to dual-eligible individuals include:
- Adult Day Care / Adult Day Health
- Personal Care Assistance (at home, adult foster care homes, and assisted living facilities)
- Medical / Non-Medical Transportation
- Respite Care (to give the primary caregiver a break)
- Congregate Meals / Meal Delivery
- Home Health Aide / Skilled Nursing
- Home Modifications (widening of doorways, installation of ramps, addition of pedestal sinks to allow wheelchair access, etc.)
- Personal Emergency Response Systems
- Housekeeping / Chore Services
- Companion Services
- Transition Services (from a nursing home back to home)
- Therapies (physical, occupational, and speech)
- Medication Administration
Can You Be Dual Eligible With Medicare Advantage
Medicare Advantage is supposed to cover at least all of the same services and treatments as Original Medicare. Therefore, it is possible to enjoy the benefits of dual eligibility with Medicaid and Medicare Advantage.
In fact, some states offer Medicare Advantage plans designed explicitly for dual-eligible beneficiaries, with no premiums or deductibles. However, because private insurers administer Medicare Advantage, there could be differences in how these plans operate compared to dual eligibility with Original Medicare.
Additional Healthcare Options for Dual Eligible Individuals
Gaining eligibility for both Medicare and Medicaid provides robust healthcare options for those who need it. However, other options are also available to this population, such as Medicaid Managed Care, Dual Eligible Special Needs Plans (D-SNP), and Programs of All-Inclusive Care for the Elderly (PACE).
Medicaid Managed Care
Medicaid Managed Care is a plan where most physical, dental, and vision care is provided by one healthcare organization. About 82% of Medicaid beneficiaries are in a managed care plan.
Medicaid Managed Care varies by state and may be called different things, such as a Coordinated Care Organization (CCO) or an integrated health plan. These plans may offer services that Medicare doesn’t, such as a ride to the doctor’s office, provided through Medicare Advantage’s dual-enrollment plans.
But once again, much varies by state. In some states, you may be unable to sign up for Medicaid Managed Care if you have Medicare.
Dual Eligible Special Needs Plans (D-SNP)
D-SNP stands for dual eligible special needs plans, a type of Medicare Advantage plan. These state-managed D-SNPs help members get referrals, plan treatments and may provide mental health services.
However, these plans can limit membership. For example, a D-SNP might only cover one type of chronic condition. These plans are designed to meet members’ specific needs, including benefits, Part D Medicare drug coverage, and a provider specialist network. Depending upon the plan, you may need to pay a monthly premium, an annual deductible for drug coverage, and other copays for services or specialists.
Programs of All-Inclusive Care for the Elderly (PACE)
Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program. You can join PACE whether you have Medicare or Medicaid, or both. You must be 55 or older, live in a PACE organization’s service area, and need nursing-home-level care. PACE covers adult day primary care, including your doctor and recreational therapy nursing services.
PACE could provide these long-term services for free if you’re on Medicaid. If you are not eligible for Medicaid, you’ll pay a monthly premium for long-term care and medications.
However, you must live in a PACE service area determined by ZIP code. PACE programs are often concentrated in and near larger urban areas, so those in rural communities may face access issues.
Costs Associated With Dual Eligibility
Both forms of insurance limit the out-of-pocket costs you must pay, but you may still need to pay for some things out of pocket. While Medicaid may pay for some Medicare costs, Medicare often doesn’t pay for Medicaid costs.
Original Medicare may ask you to pay for deductibles, copays for Part A inpatient stays and services, and Part B premiums and services. For Part D (drug coverage) plans, you’ll likely pay a premium, deductibles, and copays. Original Medicare has no yearly limit on what you pay out-of-pocket, but all Part B premium costs are similar no matter where you live.
Medicaid can help pay some of Medicare’s out-of-pocket expenses, including your Part B monthly premiums, and provides extra help with drug costs. But other Medicaid cost coverage depends upon your income and eligibility regarding Medicare:
- Part A premiums
Medicare Advantage plans are provided by private insurance companies and wrap together Medicare Part A and Part B, bundled with drug coverage. Typically, you only visit care providers within an established Medicare Advantage network and may need referrals to see a specialist.
Unlike Original Medicare, Medicare Advantage plans offer varying premiums, deductibles, coinsurance, copayments, and out-of-pocket limits depending on your provider and location.
However, as with Original Medicare, Medicaid can help cover some or portions of your out-of-pocket Medicare Advantage costs, depending on your income.
Premiums and other cost-sharing vary for Medicaid, depending on your income and state. Medicaid enrollees aren’t charged premiums if making an income 150% below the federal poverty level. According to recent surveys, possible premium charges vary by state and range from approximately $5 to $74 per month.
The federal government caps your out-of-pocket costs (for premiums and cost-sharing) at no more than 5% of your family income. Other out-of-pocket copayments you may be required to pay include the following:
- Institutional care
- Non-institutional care
- Non-emergency ER use
Each of these copayments is capped, however, based on your income. For example, if your income is 100% of the federal poverty level, you pay a $75 copayment for inpatient hospital care.
How To Dual Enroll In Medicare and Medicaid
Most dual enrollees already have Medicaid at the time of Medicare enrollment. But you may need to go through the steps.
Enroll In Medicaid
Contact the Medicaid office for your state to find out whether you can qualify for Medicaid. Each state may have different requirements around income or other factors, but you may be able to apply online and prove your low income and lack of assets. Filling out an application on the Health Insurance Marketplace can be another way to enroll in Medicaid.
Enroll In Medicare
You can use the Medicare plan finder tool to explore different options. In general, the time to enroll is at age 65. You technically have seven months to apply. The initial enrollment period starts three months before you turn 65, the month you turn 65, and ends three months after you turn 65.
If you miss this window, you can switch, drop, or join a Medicare plan from October 15 – December 7. If you’re already enrolled in a Medicare Advantage Plan, you can switch to a different Medicare Advantage plan from January 1 – March 31 each year.
Check Your Eligibility For Associated Programs
It’s wise to check with your state’s Medicaid office to determine your eligibility for any associated programs, including D-SNPs, integrated Medicare-Medicaid plans, or PACE. You might also be able to contact your state’s aging and disabilities services, an area agency on aging, or a social worker if you already have one.
Should You Take Advantage of Dual Eligibility?
In many situations, if you’re dual eligible for Medicaid and Medicare, it may be a good idea to use both forms of insurance. Consider these factors.
You Should Take Advantage of Dual Eligibility If…
Consider dual eligibility if you:
- Are Low Income: Requirements vary, but generally, your income must be less than $1,235-$4,945 per year, with slightly higher limits in Alaska and Hawaii.
- Few Assets: You must have less than $9,090 in assets.
- Qualify for Medicaid: Medicaid requirements vary by state but include income requirements, a disability, blindness, and other qualifications.
- Need Services: Specifically, nursing home and personal care services not covered by Medicare.
- Are Organized: You or a trusted care person can renew your Medicaid renewal every year to ensure you stay qualified.
Here are a few advantages of dual eligibility:
- Savings: Medicaid can help you save on your Medicare healthcare spending due to assistance with premiums, copayments, deductibles, and other out-of-pocket costs.
- More Coverage: Medicaid may be able to help pay for necessary senior services that Medicare does not, including home health, skilled care, and management of chronic conditions.
- Specialized Plans: Some dual-eligible plans can assist you if you have special or chronic healthcare needs.
- Care Integration: Depending on your state of residence, you may be eligible for a plan that integrates all aging care needs and services, including medical, dental, and mental health benefits.
Here are a few disadvantages of dual eligibility:
- State Differences: State-by-state Medicaid income qualifications and exceptions can be challenging to figure out independently, particularly if you move.
- Complicated: Surveyed seniors say barriers include the complex Medicaid application process, including income verification through pay stubs and tax returns.
- Limited Providers: Depending on where you live, you may need help finding a provider or network.
- Renewal: You’ll likely need to stay on top of your Medicaid enrollment and possibly requalify.
Can You Lose Your Dual Eligibility?
The 2023 Omnibus Appropriations bill requires states to re-evaluate who is Medicaid eligible beginning April 1, 2023. During the 2020 COVID-19 emergency, those eligible for Medicaid enjoyed continued coverage without needing to reapply or re-enroll.
Each state will review Medicaid recipients’ eligibility within the next year as part of the reevaluation process. Those who no longer qualify lose coverage. This is also true of those using D-SNP. The reevaluation process depends on the state but generally requires income verification. If your income increases, you could lose Medicaid eligibility. However, you will be notified in advance with alternative options for coverage and can appeal.
Parting Thoughts On Medicare/Medicaid Dual Eligibility
Many people feel overwhelmed by the research and work involved in becoming dual eligible for Medicaid and Medicare. But despite the hassles, dual eligibility can be worth it if reducing your out-of-pocket costs as healthcare becomes more expensive with age. In addition, you may find state-based plans that offer more than either Medicare or Medicaid alone.