Dual Eligible for Medicare and Medicaid

Dual Eligible for Medicare and Medicaid

Medicare and Medicaid though sound similar are two completely different federal government programs. Medicare plan is designed to provide healthcare to the elderly or disable people, whereas Medicaid plan is designed to offer healthcare to the economically weak section. According to the Centers for Medicare and Medicaid Services, till February 2020 around 12 million people were eligible for both Medicare and Medicaid programs. These beneficiaries are dual-eligible for both these programs and so they need to understand how both these programs work together to make the most of their healthcare experience.

Eligibility Criteria for Dual Benefits 

Eligibility to qualify for the Medicaid program is set by the federal government and is the same irrespective of the area where one is living. To qualify for Medicare program people should be 65 years of age or older or should have a qualifying disability, and should be fulfilling U.S. citizenship or permanent legal residency requirements.

Eligibility for Medicaid varies geographically, despite the federal government setting the minimal program requirements, the Medicaid program is run by the individual states, and each state has the option to adjust its eligibility standards. Medicaid provides healthcare to individuals with low income across various categories such as children, parents, seniors, pregnant women along with individuals with disabilities. With the coming up of the Affordable Care Act, adults without children can also be covered under Medicaid if their state has accepted the terms of Medicaid expansion.

It is also possible that people may be eligible for Medicaid benefits based on their income and assets. The other way to meet the criteria for Medicaid is to qualify for any of the benefits of Medicare Savings Programs offered through the local Medicaid office. People who are eligible for Medicare and meet the criteria for Medicaid eligibility or any one of the following four programs then they will be dual-eligible for both these programs:

  • Qualified Medicare Beneficiary Program
  • Specified Low-Income Medicare Beneficiary Program
  • Qualifying Individual Program
  • Qualified Disabled Working Individual Program
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Prescription Drug Costs 

As per the Medicaid requirements, individuals need to sign up for prescription drug coverage either through Medicare Part D plan or through Medicare Advantage plan having prescription drug benefits. However, if individuals participate in the Extra Help program which is a low-income subsidy program for obtaining prescription drug benefits, they should enroll in the Original Medicare and Medicare Part D plan and not in a Medicare Advantage Plan. Some of the medications that are not covered under the Medicare plan will be covered by the Medicaid plan.

Nursing Home Costs

People must be aware that Medicare does not pay for stays in skilled nursing facilities after hospitalization because it does not contribute to long-term nursing care. Though in 2020 after qualifying hospital stays, Medicare Part A benefits started paying for all nursing home expenses for up to 20 days, and from days 21 to 100 individuals will need to pay a copayment of $176 per day, and for nursing home stays longer than that, individuals will have to pay the full amount. With an increasing number of seniors having dementia and other chronic conditions, people are unable to take care of themselves. Thus, the benefit of nursing home care is essential for many people and dual-eligible people can use Medicaid to pay for long-term nursing home care.

Health Services Not Covered by Medicare

People need to know that Medicare is not a comprehensive health insurance program, and does not include healthcare services like dental, hearing, vision screenings, dentures, hearing aids, or corrective lenses. Thus, individuals whose state Medicaid program offers these services, they will benefit from the added coverage.

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Health Care Payment 

Generally, individuals enjoying the dual benefits of both the Medicare and Medicaid programs should know that Medicare pays first for the received healthcare, and then Medicaid pays. The healthcare cost that is not paid by Medicare is often paid by Medicaid. However, there is a limit on the amount paid by Medicaid in each state.

A few fortunate people may qualify for the Medicare Savings Program, which may help to cover the additional costs. For individuals qualifying for the Qualified Medicare Beneficiary program, Medicaid pays their Medicare costs like Part A premium, Part B premium, coinsurance, deductibles, and copayments. This is covered even if a Medicare service is not covered by Medicaid if individuals visit a healthcare provider who does not accept Medicaid. Individuals who do not qualify for the Qualified Medicare Beneficiary program, then Medicaid may pay less. In these circumstances, states are not required to pay if the Medicare service is not a Medicaid service, or if the beneficiary visits a Medicare provider who is not also a Medicaid provider. Some of the other Medicare Savings programs also reduce out-of-pocket costs but these programs are not extensive in their benefits.


Thus, it can be said that individuals should not assume that because they are on Medicare they will not qualify for Medicaid. However, the fact is that millions of seniors are eligible for both programs. Therefore, if individuals are struggling to make ends meet in their retirement years, then they can check their eligibility for Medicaid because this may prove to be the most reasonable way to cut their healthcare costs.

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