What Is Dual Eligibility? How to Qualify for Both Medicare and Medicaid

What Is Dual Eligibility? How to Qualify for Both Medicare and Medicaid
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What Is Dual Eligibility? How to Qualify for Both Medicare and Medicaid

What Is Dual Eligibility? How to Qualify for Both Medicare and Medicaid
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Enrolling in Medicare or Medicaid can help you fund the costs of your health care. Find out what it means to be dual eligible and whether you should apply.

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What Is Medicare?

Medicare is a federal health insurance program for older people (65 and over), younger people with disabilities, and individuals who have ESRD (End-Stage Renal Disease). 

Medicare groups medical expenses in three separate areas: Part A, Part B, and Part D.

Original Medicare is the insurance plan run by the federal government, which people use to cover their Medicare Part A and B costs.

Medicare Advantage (Part C) is made up of plans that private health insurance companies offer. These plans cover Part A and B expenses and sometimes Part D costs.

Your Medicare coverage (Original Medicare and Medicare Advantage) can take care of:

Part A expenses - relates to hospital treatment or inpatient services. 

Part B costs - refers to general medical care or outpatient services. 

Part D charges - covers self-administered prescription drugs.

An Overview of Medicare Costs

Part A is free if you have contributed towards Medicare through your taxes for at least 10 years. However, some people have to pay a monthly premium between $274.00 and $499.00.

Part B is voluntary and funded through monthly premiums, which are based on your annual income. A person who earned $91,000.00 in 2020 can expect to pay a $170.10 monthly premium.

Part C or Medicare Advantage plans range in price. Some plans charge $0 per month, while others can charge a few hundred dollars to enroll. Medicare Advantage members are still liable for Part A and Part B costs. 

Part D prescription drug coverage is also funded by monthly premiums. Prices are based on the plan’s premiums and your income-adjusted rate. The average monthly premium in 2021 was $33.00. 

Medicare members are also liable for deductible costs for Part A, B, and D coverage. 

In 2022, the deductible costs are:

  • $1556.00 for Part A
  • $233.00 for Part B
  • For Part D, costs vary based on your plan.

Source: Medicare.gov

What Is Medicaid?

Medicaid is a federal government and state health care program for low-income individuals of any age in the U.S.

This health insurance offers affordable health care options to people who can't afford to pay for medical items, services, and treatments.

Medicaid eligibility and cover varies from state to state, which means that some parts of the U.S. have more comprehensive Medicaid plans than others.

Most Medicaid enrollees don't pay anything for their health care. However, depending on the state you live in, there are still expenses that aren't covered by Medicaid.

Types of Medicaid Coverage

Mandatory Medicaid benefits are mandated by the federal government. They include inpatient hospital services, laboratory services, outpatient services, and physician services.

Optional Medicaid coverage is state-specific and can include medical insurance for prescription drug coverage, dental services, occupational therapy, and hospice care.

What Is Dual Eligibility?

There are a variety of reasons why people may struggle to cover the costs of Medicare insurance. 

Some may even feel forced to end their Medicare health coverage to avoid mounting monthly premiums and medical expenses.

The Center for Medicare and Medicaid Services (CMS) provides a way for these people to keep their Medicare cover by signing up for Medicaid.

These people are known as “dual eligible” because they are eligible for both Medicaid and Medicare health care coverage at the same time.

Once you are enrolled as dual eligible, Medicaid funds the cost of maintaining Part A and Part B coverage. 

Medicare and Medicaid enrollment has been steadily increasing over the past two decades.

Graph showing the number of dually eligible and Medicare-only beneficiaries

As seen above, the number of dual-eligible enrollees in the U.S. increased by over 3.5 million people between 2006 and 2018. However, this rise has not kept up with new Medicare-only enrollment rates.

Who Can Apply for Dual Eligibility?

To qualify for dual eligibility, you need to meet the enrollment criteria for both the Medicare and Medicaid program. 

To get Medicare coverage, you will need to be either:

  • 65, or turning 65 in the next three months.
  • Disabled.
  • Suffer from ESRD (End-stage Renal Disease).

To get Medicaid coverage, you will need to:

  • Be a citizen or lawful permanent resident of the U.S.
  • Be a resident of the state in which you are receiving Medicaid coverage.
  • Pass a state-specific income and asset eligibility test to determine if you qualify.

Specific individuals are exempt from the income eligibility requirement. You can learn more about this by visiting the Medicaid.gov website.

If you meet both the Medicare and Medicaid enrollment criteria you will become dual eligible, and Medicaid will assist in covering the cost of your Medicare coverage.

Income and asset requirements are different for each state. Here are three examples to show you what these are in 2022 for different parts of the U.S.

Maximum individual yearly income amounts for Medicaid eligibility

California Montana Alaska
$17,131 (before taxes) $12,880.00 (before taxes) $21,400.00 (before taxes)

(Sources: https://www.benefits.gov/benefit/1620; https://www.benefits.gov/benefit/1633; https://www.benefits.gov/benefit/1619)

Part A and B Financial Help

Once you're dual eligible, you’ll be able to use your Medicaid to pay some or all of your Original Medicare premiums and health care costs.

But just remember that the type of benefit status you have as a dual eligible will affect how you can use your Medicaid to cover your Medicare.

With some dual-eligible benefit types, you will only be able to use your Medicaid insurance to pay for one part of Medicare (Part A or Part B).

With other dual-eligible types, you'll be able to cover the entire cost of enrolling in Medicare. In these cases, Medicaid will pay your Medicare premiums, your deductibles, and your coinsurance amounts.

Key Facts about Dual Eligibles in the U.S. 

  • In 2020, there were 12.3 million dually eligible beneficiaries enrolled in Medicare and Medicaid.
  • Dual eligibles account for around 20% of all Medicare enrollees and 15% of Medicare enrollees.
  • In 2019, Wyoming had the lowest number of dual eligibles (10,796), and California had the highest (1,460,500).

(Sources: Macpac; KFF)

Dual-Eligible Benefit Types

There are six types of dual-eligible beneficiaries. Each one has its own financial requirements to enroll and offers other relief from Medicare health care costs. 

Depending on your age, disability status, assets, and income, you can qualify as fully dual eligible or partially dual-eligible.

Because Medicaid varies by state, there will be different requirements to qualify each benefit type. It's best to check with your local Medicaid office to learn about Medicaid criteria in your state.

Key Terms for Dual-Eligible Enrollment

FPL - Federal Poverty Level The Federal Poverty Level is the minimum yearly income that individuals or families need to pay for essentials. 

FFP - Federal Financial Participation The Federal Financial Participation is the portion of money paid by the federal government for Medicaid, Medicare, and other services.

FMAP - Federal Medical Assistance Percentage Federal Medical Assistance Percentage is the federal government’s portion of financial contributions towards Medicare, Medicaid and other medical program expenses.

SSI - Supplemental Security Income Supplemental Security Income is a financial assistance program for disabled children, disabled adults, and individuals (65 and older).

Below is a breakdown of full and partial dual-eligible categories and how they will affect your Medicare costs.

Qualifying Medicaid Beneficiary (QMB)

2022 Financial Criteria to Qualify for QMB Status

Maximum Monthly Income Maximum Asset Level
Individual Couples Individual Couples
$1,094.00 $1,472.00 $7,970.00 $1,1960.00
FPL FFP
100% or less Equals FMAP

What is Qualified Medicare Beneficiary Status?

QMB is for people who are eligible for partial Medicaid coverage. Medicare providers will not be allowed to bill you for Medicare-covered services and items. However, you may still be charged for prescription drugs (Part D expenses).

What does QMB cover?

If you have QMB status, it will mean that your Medicaid coverage will pay for Part A and B premiums. In some cases, Medicaid might also cover the costs of your deductibles, coinsurance, and copayments.

Qualifying Medicaid Beneficiary Plus (QMB+)

2022 Financial Criteria to Qualify for QMB+ Status

Maximum Monthly Income Maximum Asset Level
Individual Couples Individual Couples
$1,094.00 $1,472.00 $7,970.00 $1,1960.00
FPL FFP
100% or less Equals FMAP

What is Qualified Medicare Beneficiary Plus Status?

QMB+ is for people who have lower incomes than standard QMB individuals and qualify for full Medicaid cover. If you become a QMB+ beneficiary, you will receive full Medicaid benefits and be able to receive free or heavily subsidized medical services.

What does QMB+ status cover?

As a QMB+ you will receive full Medicaid benefits, and Medicaid will pay for your Medicare Part A and B premiums. Your Medicaid will also cover the costs of your Medicare deductibles and coinsurance amounts (for both Part A and B).

Specified Low-Income Medicare Beneficiary (SLMB)

2022 Financial Criteria to Qualify for SLMB Status

Maximum Monthly Income Maximum Asset Level
Individual Couples Individual Couples
$1,308.00 $1,762.00 $7,970.00 $1,1960.00
FPL FFP
At least 100% but less than120% Equals FMAP

What is a Specified Low-Income Medicare Beneficiary Status?

SLMB individuals exceed the usual financial criteria for full Medicaid coverage. However, they are still eligible to receive partial Medicaid assistance for Medicare costs and Medicaid health care.

What does SLMB status cover?

SLMB status will mean that Medicaid will pay for your Part B premiums only. You will not be covered for Part A premiums or other Medicare-related costs such as deductibles, coinsurance or Part B premiums.

Specified Low-Income Medicare Beneficiary Plus (SLMB+)

2022 Financial Criteria to Qualify for SLMB+ Status

Maximum Monthly Income Maximum Asset Level
Individual Couples Individual Couples
$1,308.00 $1,762.00 $7,970.00 $1,1960.00
FPL FFP
At least 100% but less than120% Equals FMAP

What is Specified Low-Income Medicare Beneficiary Plus status?

SLMB+ status is similar to SLMB status except that you qualify for full Medicaid benefits.

What does SLMB+ status cover?

If you get SLMB+ status, Medicaid will cover the cost of your Part B premiums, and you will get Medicaid benefits to cover your health care expenses. Medicaid will not cover your Part A premiums and other Medicare-related costs.

Qualified Disabled and Working Individual (QDWI)

2022 Financial Criteria to Qualify for QDWI Status

Maximum Monthly Income Maximum Asset Level
Individual Couples Individual Couples
$4,379.00 $5,892.00 $4,000.00 $6,000.00
FPL FFP
200% or less Equals FMAP

What is Qualified Disabled and Working Individual status?

If you are classified as a QDWI dual eligible, you may be eligible for Medicare benefits but unable to afford the associated costs. QDWI is more common among people under the age of 65.

What does QDWI status cover?

Medicaid will cover the cost of your Part A monthly premium but not your other Medicare Part A and Part B costs.

Qualifying Individual (QI)

2022 Financial Criteria to Qualify for QI Status

Maximum Monthly Income Maximum Asset Level
Individual Couples Individual Couples
$1,496.00 $1,980.00 $4,000.00 $6,000.00
FPL FFP
At 120% but lower than 135% Equals FMAP at 100%

What is a Qualified Individual status?

Qualified Individual status is for individuals who qualify as dual eligibles but aren't in any of the above categories.

What does QI status cover?

Qi status means that Medicaid will only pay for your Medicare Part B premium. It will not cover Part A premiums and out-of-pocket expenses. It will not cover Part B deductibles and coinsurance costs.

Dual Eligible and Medicare Advantage

Certain dual eligibles are still allowed to enroll in Medicare Advantage plans. These are called Special Needs Plans (SNPs) and are designed to cater to dual eligibles and other specific groups.

You can learn more about Medicare Advantage by reading our guide, What is Medicare Part C?

If you have questions about finding or enrolling in a dual-eligible Medicare Advantage plan, reach out to PolicyScout via email.

How Can I Find Out More about Dual Eligible and Medicare?

You can learn more about Medicare, Medicaid, and health insurance by visiting PolicyScout’s Medicare Hub. We publish informative articles, reviews, and reports on Medicare-related topics.

Contact our Medicare consultants if you have any questions about dual eligibility or would like to find the best Medicare Advantage plans in your state. 

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