Site Links HomeMedicare BasicsBlog ArticlesFind an AgentTurning 65 Medicare Answers Call a Local AgentFind the Right Plan LEGAL Privacy Policy©2020 LMS Insurance, LLC – All Rights ReservedPerson getting Medicare and Medicaid benefitsPublished on: 08/06/2024

Dual Eligibility for Medicare and Medicaid Explained

In 2024, approximately 7.2 million seniors on Medicare will receive assistance from Medicaid, as per the Medicaid program's data. Additionally, 4.8 million individuals who qualify for Medicare due to disabilities are also eligible for Medicaid. With around 12 million dual-eligible beneficiaries, it is essential to understand the eligibility criteria for both Medicare and Medicaid and how these programs collaborate to deliver benefits.

Medicare functions as health insurance provided by the federal government, whereas Medicaid offers assistance from the state government for those with income below a specific level.

Original Medicare is divided into two primary parts: Part A, which covers hospital benefits, and Part B, which covers medical benefits. Since they are federally administered, these benefits are standardized for all enrollees.

Medicaid eligibility thresholds are determined by each state, so qualifying for Medicaid can vary depending on where you live. If you qualify for Medicaid and are also eligible for Medicare, understanding the coordination between the two programs is crucial.

Can You Have Medicaid and Medicare at the Same Time?

Yes, it's possible to have both Medicaid and Medicare simultaneously since they are separate programs. When eligible for both, individuals qualify for what is known as a Medicare Savings Program. There are four such programs:

  1. Qualified Medicare Beneficiary (QMB): Under this program, Medicaid covers Part A and Part B premiums as well as cost-sharing after Medicare's initial coverage. Eligibility also grants access to the Extra Help program for prescription drugs. If qualified as a QMB, there's no need for a Medigap plan.

  2. Specified Low-Income Medicare Beneficiary (SLMB): Here, Medicaid covers only the Part B premium, yet individuals still qualify for Extra Help with prescription drug costs. In this scenario, enrolling in a Medigap plan could assist with covering cost-sharing after Medicare.

  3. Qualified Individual (QI): QI recipients receive the same coverage as SLMB beneficiaries.

  4. Qualified Disabled & Working Individual (QDWI): This program covers only the Part A premium through Medicaid.

Understanding the criteria and timing for eligibility in Medicare or Medicaid is crucial to ensure you receive coverage when needed.

Typically, individuals become eligible for Medicare at age 65. However, eligibility can occur before 65 if you've received Social Security Disability Income benefits for at least 24 months, or if you have End-Stage Renal Disease or Amyotrophic Lateral Sclerosis.

Medicaid eligibility, on the other hand, varies based on state regulations and personal circumstances. It can be granted to children, pregnant women, and individuals with lower income or disabilities.

If you meet the eligibility requirements for Medicaid in your state and are also eligible for Medicare, you can enroll in both programs. This is commonly seen among adults aged 65 and older with low income. However, individuals under 65 who qualify for Medicare due to disability may also be eligible for both Medicare and Medicaid before turning 65.

Benefits of Dual Eligibility

Dual eligibility for Medicare and Medicaid offers several benefits. First, certain Medicare premiums may be covered, and deductibles and cost-sharing expenses could be reduced or even entirely covered, depending on your specific Medicare Savings Program. Additionally, you can expect to receive Extra Help with your prescription drug costs. Extra Help is an additional assistance program associated with your drug plan, which may result in lower monthly premiums and copayments and help you avoid falling into the coverage gap.

Provider explaining Medicare and Medicaid benefits to a woman

How to Apply for Medicare and Medicaid Benefits

Applying for Medicare and Medicaid benefits involves separate processes. Your Medicare application is handled through Social Security. Eligible individuals have a seven-month window known as the Initial Enrollment Period, which includes three months before and after their 65th birthday month.

However, if you're already receiving Social Security benefits at least four months before turning 65, you'll be automatically enrolled in Medicare.

For those covered by creditable insurance who choose to delay Medicare past 65, the application process differs, as they may qualify for a Special Enrollment Period.

If you believe you qualify for Medicaid due to a lower income, you can apply through your state's Medicaid agency. Upon approval, they should inform you of the Medicare Savings Program you qualify for. If not, you can contact them for clarification.

Local Medicare Specialists Understand Dual Eligibility

If you qualify for both Medicare and Medicaid, you have the option to enroll in specific Medicare Advantage plans known as Dual Eligible Special Needs Plans (D-SNP). These plans are designed to meet the needs of individuals with both Medicare and Medicaid, ensuring that the provider network includes those who accept both programs.

While Medicare eligibility is based on age or disability, you have more control over your Medicaid application process. If you believe your income is low, it's advisable to apply for Medicaid to explore potential assistance opportunities.

Keep in mind that the Social Security Administration oversees your Medicare benefits, while your state's Medicaid Agency manages your Medicaid benefits.

Still Have Medicare Questions?

Schedule a FREE Medicare plan consultation with an agent in your neighborhood.

Search

Privacy and Security: Your privacy and security are extremely important to us. Your personal information is protected by our Privacy Policy

LocalMedicareSpecialists.com is privately owned and operated by LMS Insurance LLC. LocalMedicareSpecialists.com is a non-government resource for those who depend on Medicare, providing Medicare information in a simple and straightforward way.

We do not offer every plan available in your area. Currently we represent 11 organizations which offer 173 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

tracking pixel