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

Medicaid is a health insurance program run by each individual state for people who are low-income, and Medicare is a national health insurance program for all Americans over 65. People who are eligible for both Medicaid and Medicare are considered “dual eligibles.” While some benefits are available through both programs, there are also differences in coverage that make dual eligibility a good way for many seniors to pay for their care needs. Only Medicaid, for example, pays for long-term nursing home care.


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 needy people who have monthly income and assets below a certain amount, while Medicare is for all Americans who are 65 or more years old 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 through Medicare Part D, also called Medicare Advantage. More on Part D below).

 Medicare and Medicaid are both supervised by the Centers for Medicare and Medicaid Services (CMS), but Medicaid benefits are administered through the state while Medicare is approved through the Social Security Administration (SSA).

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 eligibles will be low-income and above the age of 64.

Dual eligibles receive a combination of benefits from both programs.


Medicare Benefits

Medicare is 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 eligibility criteria and services are determined at the state level. Determine your specific eligibility criteria here.  Broadly, 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.

For seniors and those with chronic health problems including Alzheimer’s and Parkinson’s disease, Medicaid Long Term Care is an extension of Medicaid (with roughly the same income and asset requirements) that provides services to help someone who cannot live independently. LTC benefits are not necessarily medical, and can include help with activities of daily living (ADLs) like eating and bathing.


Benefits of Dual Eligibility

Medicare pays first for medical services (doctors and hospitals), and if Medicare doesn’t cover the full costs of care then Medicaid can pay for the rest. If there are services one needs that Medicare does not cover, like in-home help with activities of daily living (ADLs) and nursing care, Medicaid may cover those costs.

 Medicaid Long Term Care falls under three categories: Nursing Home Medicaid, Home and Community Based Services (HCBS) waivers, and Aged, Blind and Disabled (ABD) Medicaid, which is also sometimes called “Regular Medicaid.”

Put more broadly, Medicaid offers long term care benefits that are usually for people who are older or have chronic illness that causes them to lose independence. Medicare does not cover long term care, except in the case of some Medicare Part C or Medicare Advantage plans administered through Medicare-approved private insurers. Dual eligibles, therefore, can receive the benefits of both programs.

Long term care benefits are different from regular care in that the need is ongoing and not necessarily medical. This is a list of long-term care benefits available to Medicaid enrollees that Medicare recipients cannot get covered unless they sign up for both (though remember that specific benefits will vary based on the state):
– Personal care assistance
– 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

Dual enrollees may also have their Medicare premiums, meaning the flat cost they would normally pay each month for Medicare services, covered by Medicaid through a Medicare Savings Program. Recipients of Medicare Part A might not have to pay a premium, if they have worked at least 10 years and paid into the program, but otherwise these are the usual costs for Medicare that dual enrollees can often get covered by Medicaid:

– Medicare Part A’s inpatient hospital deductible is $1,556 in 2022. Individuals who have worked less than 10 years paying into the program pay a $274 monthly premium. For full Medicare Part A coverage (meaning the recipient did not pay in while working) the cost is $499 per month.
– Medicare Part B’s standard monthly premium in 2022 is $170.10, with a $233 annual deductible.
– Medicare Part C or Medicare Advantage premiums will vary by plan.
– Medicare Part D premiums are based on income. Someone eligible for Medicaid would probably not have premium costs because they are low-income.

Exactly which type of Medicare Savings Program a dual eligible person enrolls in will depend on their health needs. These are the Medicare Savings Programs relevant to seniors, and the types of Medicare they pay for through Medicaid (income and asset limits vary depending on the state):

– Qualified Medicare Beneficiary (QMB): Pays for Part A and Part B premiums, as well as share of costs and deductibles.
– Specified Low Income Medicare Beneficiary (SLMB): Pays for Part B premiums.
– Qualifying Individual (QI): Also pays for Medicare Part B premiums. QI income limits are higher than SLMB.


Medicare PACE/LIFE

PACE (in some states called LIFE) programs are open to both Medicaid and Medicare enrollees, but dual eligibles make up 90% of its recipients. PACE works like Medicaid waivers in that they are for people who need nursing care but don’t want to move into a full-time nursing home. Recipients are expected to provide some or their own care, or in other words do not require 24-hour nursing. This makes PACE a good option for families who can provide some amount of caregiving to a medically needy loved one.

PACE stands for Programs of All-Inclusive Care for the Elderly, though in some states the same program is called LIFE (Living Independence for the Elderly) or Managed Care at Home.

PACE is not available in every state and enrollees may need to give up their primary care physician for a PACE-approved doctor. Click here to see if PACE is available in one’s area.

Medicare PACE / LIFE covers seniors’ medical care and some personal needs based on their individual situation. The program does not provide cash payments, rather Medicare or Medicaid pay on behalf of the recipient.

PACE recipients can choose among benefits including the following:

– Adult day care
– Hospital care
– Dental care
– Durable medical equipment
– Meals
– Transportation
– Lab work
– X-ray
– Optometry
– Physical therapy
– Nutritional counseling
– Skilled nursing
– Social services
– Respite care
– Prescription drugs


Eligibility & How to Apply for Medicaid & Medicare

There is no difference in eligibility criteria from state-to-state for Medicare; it’s the same throughout the US. The broad requirements for Medicare eligibility are that the applicant must be the following:
– A U.S. citizen for at least 5 years before applying
– At least 65 years old or disabled.

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

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.

For much more on eligibility for Medicaid, click here.

To apply for Medicaid, contact your nearest Medicaid office.