Dual eligible beneficiaries receive both Medicare and Medicaid benefits. This includes people who qualify for full Medicaid benefits and those who get assistance through a Medicare Savings Program, which helps with out-of-pocket Medicare costs. Like most Medicare enrollees, dual eligible beneficiaries can choose to get their Medicare coverage through Original Medicare, Part A and Part B, or from a Medicare Advantage plan offered by a private insurance company contracted with Medicare to provide Medicare Part A and Part B benefits, with the exception of hospice care, which remains a service covered by Part A.
Medicaid is a joint federal and state program. However, the program is run at the state level, and each state sets its own eligibility guidelines, including income requirements and the scope of assistance provided. To find out if you’re eligible for Medicaid, you may contact your state’s Medicaid program.
When it comes to eligibility for Medicare, most people become eligible at age 65 if they are either United States citizens or permanent residents of at least five continuous years. Other people can qualify before age 65 if they have a disability or have certain conditions, such as end-stage renal disease or amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease).
How Medicaid and Medicare work together
Medicare has four basic parts:
- Part A: Helps pay for hospitalization costs
- Part B: Helps pay for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services
- Part C: Medicare Advantage Plan (like an HMO or PPO) offered by private companies approved by Medicare to provide at least the same benefits as Original Medicare Part A and Part B (except hospice care, which is covered by Part A).
- Part D: Stand-alone Medicare Part D Prescription Drug Plans and Medicare Advantage Prescription Drug plans offered by private companies approved by Medicare to assist with the cost of prescription drugs.
Some Medicare enrollees who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medicaid through a Medicare Savings Program. There are four Medicare Savings Programs available, with each providing a different level of financial assistance:
- The Qualified Medicare Beneficiary (QMB) Program helps pay Medicare Part A and part B premiums, deductibles, copayments, and coinsurance.
- The Specified Low-Income Medicare Beneficiary (SLMB) Program helps pay Medicare Part B premiums.
- The Qualifying Individual (QI) Program helps pay Medicare Part B premiums.
- The Qualifying Disabled and Working Individuals (QDWI) Program pays Medicare Part A premiums for certain people who have disabilities but are still working.
Dual eligible beneficiaries who are eligible for the Qualifying Individual, Specified Low-Income Medicare Beneficiary, or Qualifying Medicare Beneficiary Programs will automatically be eligible to get Extra Help (Low-Income Subsidy), which helps with Medicare prescription drug costs.
Each Medicare Savings Program has different eligibility requirements, which may change from year to year. Check with your state’s Medicaid program to see if you qualify.
Some dual eligible beneficiaries qualify for full Medicaid benefits, meaning that in addition to their Medicare Part A and Part B coverage, Medicaid may also covers additional services beyond those provided under Medicare. Specific benefits may vary by state, but may include medical transportation, vision, chiropractic and dental care, nursing facility care beyond the 100-day limit that Medicare covers. If both Medicare and Medicaid cover a benefit, Medicare will pay first, and Medicaid will pay last the remaining costs after employer-sponsored insurance and/or a Medicare Supplement (Medigap) plan have paid.
Dual Eligible Special Needs Plans
Beneficiaries who receive both Medicare and Medicaid may consider enrolling in a Dual Eligible Special Needs Plan. Special Needs Plans are a type of Medicare Advantage plan that designs benefits, provider networks, and formularies to meet the unique needs of its members. For example, a Dual Eligible Special Needs Plan might cover coordinated-care services or social services that help enrollees manage their Medicare and Medicaid benefits.
To be eligible for a Dual Eligible Special Needs Plan, you must:
- Be eligible for both Medicare and Medicaid.
- Live in the service area of a Dual Eligible Special Needs Plan.
- Not have end-stage renal disease, unless you get a waiver.
Dual eligibility and Special Election Periods
Unlike most other Medicare beneficiaries, dual eligible beneficiaries have more flexibility to make changes to their Medicare coverage throughout the year. If you receive both Medicare and Medicaid, you’ll generally have a Special Election Period available on an ongoing basis, which you can use to:
- Switch from Original Medicare to a Medicare Advantage plan.
- Switch Medicare Advantage plans.
- Disenroll from a Medicare Advantage plan and return to Original Medicare.
If you’re a dual eligible, you can also use this Special Election Period to enroll in, switch, or disenroll from a Dual Eligible Special Needs Plan at any time.
If you lose your Medicaid eligibility, you’ll generally get a Special Election Period during which you may switch Medicare Advantage plans or return to Original Medicare. This period starts the month you receive notice plus two additional months after you’re notified that you’re losing your Medicaid benefits. If you receive notice that you’ll lose Medicaid eligibility for the following year, you can make coverage changes from January 1 to March 31.