Having Dual Eligibility for Medicaid & Medicare: Who is Eligible and Benefits?

Summary
Medicaid is health insurance for financially limited Americans, and it’s run by state governments. Medicare, on the other hand, is health insurance for Americans age 65 and older, and it’s run by the federal government. Seniors who are enrolled in both Medicaid and Medicare are known as “dual eligible.” These “dual eligible” seniors have all of the benefits of both Medicaid and Medicare, which results in lower out-of-pocket costs, more comprehensive coverage and more long-term care benefits.

Explaining Medicaid, Medicare, & Dual Eligibility

There are two key differences between the governmental health insurance programs Medicaid and Medicare:

• Medicaid is run by one’s state of residence, and Medicare is run by the federal government.
• Medicaid is for financially limited Americans who have monthly income and assets below a certain amount, while Medicare is for all Americans who are age 65 or older and/or disabled.

Some benefits overlap, while others do not. Both programs pay for medical costs including doctor appointments and hospital care, but only Medicaid will cover all the costs of living in a nursing home for more than 100 days. Medicaid is also the program for receiving long-term care services at home or in assisted living, as Medicare does not pay for long-term care (except in some cases through Medicare Part D, also called Medicare Advantage. More on Part D below).

To be “dual eligible,” one must meet the income requirements of their state’s Medicaid program, meaning having income and assets below a certain amount, and meet the age requirement for Medicare, meaning 65 and over. Put simply, “dual eligible” seniors will be financially limited and above the age of 64.

“Dual eligible” seniors receive a combination of benefits from both Medicaid and Medicare, and some benefits unique to those who are “dual eligible.” All three of these types of benefits are discussed below:

Medicare Benefits

Medicare and it benefits are broken into types:

• Medicare Part A provides hospital insurance (inpatient hospital care, inpatient nursing home care, hospice care, limited home health services).
• Medicare Part B is medical insurance (doctors’ appointments, outpatient hospital care, durable medical equipment for in-home use, home health services, some preventative services).
• Medicare Part C is also called Medicare Advantage, and it provides benefits through a private insurer (Part A and Part B benefits combined, with prescription drug coverage and personalized benefits based on need).
• Medicare Part D covers prescription drugs.

Relevant to long-term care, Medicare will only pay for nursing home care at 100% for 20 days and then at 80% for the following 80 days. After 100 days, Medicare pays nothing for nursing home care.

Medicaid Benefits

Medicaid follows federal rules and regulations, but benefits and eligibility criteria are determined at the state level. In general, state Medicaid programs cover visits to doctors, hospital services, labs, nursing home care, and some in-home support. For more information on state-by-state Medicaid benefits, click here. To see about your specific eligibility criteria, click here.

Medicaid Long Term Care will cover long-term care in a nursing home. It will also provide some long-term care benefits to seniors who require the kind of care found at nursing homes (known as a “Nursing Facility Level of Care”) but want to remain living in their own home or somewhere else in the community, like with a family member or in an assisted living facility. These long-term care benefits are not necessarily medical, and can include help with the Activities of Daily Living – mobility (moving in and out of bed, or to a different room), bathing, dressing, eating and toileting.

Benefits of Dual Eligibility

For “dual eligible” seniors, Medicare is the primary payer when it comes to medical costs (doctor’s visits, lab work, in-home care, etc.) and hospitalization costs for dual-eligible seniors. If those full costs are not covered, Medicaid (the secondary payer) will cover the rest, as long as the services are included in the senior’s Medicaid plan.

Seniors who only have Medicare are not covered for long-term care in a nursing home, and there are only some Medicare Part C or Medicare Advantage plans that offer any type of long-term care coverage. “Dual eligible” seniors, however, have a wide-range of long-term care benefits available though Medicaid. These benefits can be received in a nursing home, via Nursing Home Medicaid. Or they can be received where the “dual eligible” senior lives “in the community” – their own home, the home of a loved one, an assisted living facility, adult foster care, etc. – via Home and Community Based Services (HCBS) Waivers or Aged, Blind and Disabled (ABD) Medicaid.

It’s important to note that these “in the community” long-term care benefits, and the exact locations where they can be delivered, will depend on the specific Medicaid program and state. That being said, the following are examples of long-term care benefits that are not available to people with just Medicare coverage, but are available to “dual eligible” seniors:

• Personal care assistance with the Activities of Daily Living (mobility, bathing, dressing, eating, toileting)
• Transportation
• Meal delivery
• Skilled nursing care
• Home modifications
• Housekeeping
• Medication management
• Physical therapy
• Occupational therapy
• Respite care
• Adult day care
• Personal Emergency Response Systems

Medicaid Covers Medicare Premiums for Dual Enrollees

Anther unique benefit for “dual eligible” seniors is that Medicaid will pay their Medicare premiums (the monthly fee for Medicare services).

For seniors with full Medicaid coverage via Nursing Home Medicaid, HCBS Waivers or ABD Medicaid, Medicaid will pay for their Medicare Part A and Part B premiums. Anyone who worked a minimum of 10 years and paid into Medicare during that time will, in general, receive Medicare Part A (hospitalization insurance) for free. That covers about 99% of Medicare beneficiaries, according to CMS, but for individuals who did not work, the full monthly premium for Medicare Part A in 2025 is $518. For individuals who worked but did not meet the full criteria, there is a reduced rate of $285/month. The premium for Medicare Part B (medical insurance) in 2025 is $185/month. The 2025 deductible for Medicare Part A is $1,676 and for Part B the deductible is $257.

For seniors who don’t qualify for full Medicaid due to financial reasons, there are Medicaid Medicare Savings Programs with slightly less strict financial criteria that will help pay Medicare Part A and/or Part B premiums, deductibles, coinsurance and co-payments, and they will qualify the senior as “dual eligible.” These Medicaid Medicare Savings Programs are Qualified Medicare Beneficiary, Specified Low Income Medicare Beneficiary and Qualifying Individual.

Here’s a quick look at the financial requirements for full Medicaid coverage through Nursing Home Medicaid, Home and Community Based Services (HCBS) Waivers, and Aged, Blind and Disabled (ABD) Medicaid:

In most states in 2025, the income limit for Nursing Home Medicaid and HCBS Waivers for an individual is $2,901/month, and the asset limit is $2,000. Income limits for ABD Medicaid have more variance per state with the 2025 limits ranging from $967/month to about $1,800/month, while the 2025 individual asset limit for ABD Medicaid is $2,000 in most states. For a complete list of states and their financial limits, click here.

It can be helpful to compare those numbers to the financial requirements for the Medicaid Medicare Savings programs, and the 2024 requirements are listed below. The exact 2025 requirements will be released in early 2025, but they will be similar to the 2024 numbers, and the lack of any asset limit for the Medicaid Medicare Savings programs will remain the same.

• The Qualified Medicare Beneficiary (QMB) Program has a 2024 individual income limit of $1,275/month and there is no asset limit. The QMB Program pays Medicare Part A and Part B premiums, deductibles, co-insurance and co-payments.
• The Specified Low Income Medicare Beneficiary (SLMB) Program covers Medicare Part B premiums. The 2024 SLMB income eligibility limit for an individual in most states is $1,506/month and there is no asset limit.
• The Qualifying Individual (QI) Program pays Medicare Part B Premiums for individuals who have no other Medicaid eligibility. The 2024 QI income eligibility limit for an individual in most states is $1,695/month, and there is no asset limit.

The chart below uses approximate figures for most states:

Program of All-Inclusive Care for the Elderly (PACE)

The Program of All-Inclusive Care for the Elderly (PACE) is open to any senior, but “dual eligible” individuals make up about 90% of program participants. PACE coordinates medical, social service and non-medical personal needs into one comprehensive plan and delivery system, including both Medicare and Medicaid benefits for the “dual eligible.” PACE also administers vision and dental care, and PACE day centers provide adult day care, meals, social activities and regular health checkups.

PACE is also known as LIFE (Living Independence for the Elderly) in some states. But PACE/LIFE programs are not available in every state. Click here to see if a PACE/LIFE Program is available in your area. For more on PACE/LIFE, click here.

Eligibility & How to Apply for Medicaid & Medicare

Medicare
There is no difference in eligibility criteria from state-to-state for Medicare; it’s the same throughout the U.S. Anyone age 65 or older is eligible for Medicare, as long as they are also a U.S. citizen, or a legal U.S. resident who has lived in the country for at least 5 years immediately prior to applying for Medicare. Citizens or legal residents who are disabled, have Lou Gehrig’s disease or end-stage renal disease are also eligible for Medicare, but this article is focused on seniors.

To apply for Medicare, contact the nearest Social Security Office.

Medicaid
Medicaid eligibility is complicated and will vary depending on several factors including one’s financial situation and state of residence.

To enroll in Medicaid, one’s monthly income and countable assets must be below a certain amount that, again, will vary depending on the state. Our Medicaid Long Term Care Eligibility Requirements Finder is a great place to start learning the eligibility requirements specific to your state, type of Medicaid and marital status. If you’re over your financial limits or want to talk to a professional for some other reasons, contacting a Certified Medicaid Planner is a good place to start.

For much more on eligibility for Medicaid, click here.

To apply for Medicaid, contact your nearest Medicaid office.