Jeffrey Wade
Medicare and Medicaid are both health insurance programs, but they are different in many ways. Medicare is a federal health insurance program for seniors and disabled persons, while Medicaid is a state and federal medical assistance program for financially needy persons of any age. Medicare is the primary source of health insurance coverage for dual-eligible individuals, with Medicaid providing supplemental coverage. Dual eligibility allows beneficiaries to combine Medicare and Medicaid benefits to expand coverage and assist with costs. This means that Medicare benefits are paid first, and Medicaid covers any costs not fully covered by Medicare.
| Characteristics | Values |
|---|---|
| What is dual eligibility? | Dual eligibility refers to persons who are eligible for both Medicare and Medicaid. |
| Who are dual eligibles? | Dual eligibles are also called "dually eligible beneficiaries" or "Medicare-Medicaid enrollees". |
| How many people are dual eligibles? | As of March 2024, 12.5 million individuals were enrolled in both programs. |
| Who is eligible for Medicare? | Medicare is available to people aged 65 and over and those with qualifying medical conditions. |
| Who is eligible for Medicaid? | Medicaid is available to people with limited income or financial resources. |
| What are the different parts of Medicare? | Medicare Part A (Hospital Insurance), Part B (Medical Insurance), Part C (Medicare Advantage), and Part D (Prescription Drug Coverage). |
| What are the costs associated with Medicare? | Medicare Part B has a monthly premium of $185 and an annual deductible of $257. Medicare Part C has a monthly premium of approximately $17 on average. |
| How does dual eligibility work? | Medicare is the primary source of health insurance coverage for dual eligibles, and Medicaid provides supplemental coverage. |
| What are the benefits of dual eligibility? | Dual eligibility provides greater healthcare coverage by combining the benefits of both programs. Medicaid covers additional costs and services not included in Medicare, such as long-term nursing home care and personal care services. |
| Are there any concerns or challenges? | There are concerns about the lack of integration between Medicare and Medicaid, which may lead to fragmentation of care, poor outcomes, and high costs. |
| How can coordination be improved? | Higher enrollment in Medicare Advantage plans designed for dual eligibles (Dual-Eligible Special Needs Plans, or D-SNPs) may help address fragmentation challenges. |
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What You'll Learn
Medicare and Medicaid eligibility requirements
Medicare is federal health insurance for anyone aged 65 and older, as well as some people under 65 with certain disabilities or conditions. Medicare insurance is also available for people with End-Stage Renal Disease.
Medicare Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care services. Medicare Part B helps cover medical services like doctors' services, outpatient care, and other medical services that Part A doesn't cover. Medicare Part D is prescription drug coverage.
Medicaid, on the other hand, is a joint federal and state program that provides health coverage to certain low-income individuals and families, including children, parents, pregnant women, the elderly, and people with disabilities. Eligibility rules differ among states, and generally, one must meet their state's rules for income and resources, as well as residency requirements. Some states have expanded their Medicaid programs to cover other adults below a certain income level.
Individuals who are enrolled in both Medicaid and Medicare are considered "dually eligible" and can be covered for both optional and mandatory categories. In these cases, Medicare pays first for Medicare-covered services, and Medicaid pays last, after Medicare and any other health insurance the individual might have. If you are dually eligible, Medicare will cover your prescription drugs, and you will be automatically enrolled in a Medicare drug plan. However, Medicaid may still cover some drugs that Medicare does not.
To apply for Medicaid, you can create a Marketplace account on HealthCare.gov and complete an application. If your application shows that someone in your household might qualify for Medicaid, it will be forwarded to your state for a final eligibility decision.
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$1211.99
How to enrol in both programs
To enrol in both Medicare and Medicaid programs, you must meet the eligibility requirements for both. Here is a step-by-step guide on how to enrol and become a "dual eligible" individual:
Step 1: Understand the Eligibility Requirements
Medicare is a federal health insurance program with consistent eligibility requirements across the United States. To be eligible for Medicare, you must meet one or more of the following criteria:
- Be a US citizen or a legal US resident living in the US for at least the last five years.
- Be 65 years of age or older.
- Have a disability.
- Have end-stage renal disease.
- Have Lou Gehrig's disease (amyotrophic lateral sclerosis).
Medicaid, on the other hand, is a state and federal medical assistance program with varying eligibility requirements across different states. The general requirement for Medicaid is that you must have limited income and resources, but the specific income and asset limits differ from state to state.
Step 2: Enrol in Medicare
To be considered a dual eligible, you must be enrolled in Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance). You can enrol in Medicare by visiting the official website or contacting 1-800-MEDICARE.
Step 3: Enrol in Medicaid
To enrol in Medicaid, you must meet your state's specific eligibility criteria regarding income and resources. Contact your state's Medicaid office or visit their official website to enrol and find out about the specific requirements and benefits offered in your state.
Step 4: Understand How the Programs Work Together
Once you are enrolled in both programs, it is important to understand how they work together. Medicare is typically the primary source of health insurance coverage for dual eligibles, and Medicaid provides supplemental coverage. Medicare covers a range of services, and if there are any remaining costs or additional services needed, Medicaid steps in to provide coverage up to the state's payment limit.
Step 5: Explore Special Plans for Dual Eligibles
There are special plans designed specifically for dual eligibles, such as Dual-Eligible Special Needs Plans (D-SNPs) and Medicare Advantage plans. These plans can help improve the coordination of care and make it easier for you to access the services you need. Contact Medicare or consult with a licensed insurance agent to explore the options available in your area.
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Benefits of dual eligibility
Dual eligibility, or being dually eligible, refers to having both Medicare and Medicaid coverage. In 2020, just over half (51%) of dual-eligible individuals received their Medicare benefits through traditional Medicare, while the remaining 49% were enrolled in Medicare Advantage plans.
Medicare is the United States' federal health insurance program, while Medicaid is an assistance program provided jointly by federal and state agencies. To be considered dually eligible, a person must be enrolled in Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance). They must also be enrolled in either full-coverage Medicaid or one of Medicaid's Medicare Savings Programs (MSPs).
Medicare Advantage plans (also known as Medicare Part C) are private insurance plans that provide all of Part A and Part B coverage and typically offer extra benefits such as vision, hearing, and dental care. These plans often provide some coverage of supplemental benefits, such as durable medical equipment, and may offer long-term home and community-based services.
The benefits of dual eligibility include the ability to receive a broader range of healthcare services. Medicaid offers benefits not normally covered by Medicare, like nursing home care, personal care services, and long-term care and supports in home and community-based settings. Medicaid may also cover some drugs that Medicare doesn't cover. Additionally, Medicaid can provide premium and cost-sharing assistance through the Medicare Savings Program.
For individuals who are dually eligible, Medicare is typically the primary plan and covers most Medicare-eligible healthcare services. Medicaid then acts as the secondary plan and may cover medical costs that Medicare doesn't cover or only partially covers. This coordination between the two programs ensures that dual eligibles can access the services they need and may result in cost savings.
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Out-of-pocket costs for dual-eligible individuals
Out-of-pocket expenses refer to the amount that an individual must pay out of their own funds for healthcare services. For dual-eligible individuals, the out-of-pocket costs can vary depending on their level of eligibility and the specific benefits covered by their state's Medicaid and Medicare programs.
Full dual eligibles receive full state Medicaid benefits and Medicare. Medicare pays for most covered care and benefits, while Medicaid covers some out-of-pocket costs like copays, coinsurance, deductibles, and premiums. Medicaid also covers long-term care and other benefits not included in a Dual Special Needs Plan (D-SNP). As a result, dual eligibles may have lower out-of-pocket costs compared to those with only Medicare or Medicaid.
Partial dual eligibles, on the other hand, qualify for Medicare Savings Programs (MSPs) and may receive full or partial Medicaid benefits. MSPs help cover some out-of-pocket costs, such as Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments. However, partial dual eligibles may still be responsible for some out-of-pocket expenses, especially if they have Medicare Advantage (MA) plans.
Qualified Medicare Beneficiaries (QMBs), a specific category of dual eligibles, have all cost-sharing expenses (premiums, deductibles, coinsurance, and copayments) for Parts A and B excused. The state is responsible for these payments regardless of whether the service is also covered by Medicaid. For non-QMB dual eligibles, states are obligated to pay up to the Medicaid rate for Medicaid services provided by Medicaid providers, but only for costs above any third-party liability, such as traditional Medicare or an MA plan.
Additionally, Medicaid may cover cost-sharing amounts owed under Medicare, including deductibles, coinsurance, and copayments. This applies to partial dual eligibles who are disabled and working, with incomes above the state's full Medicaid threshold but below specific FPL percentages.
It is important to note that out-of-pocket costs for dual eligibles can vary by state, as states have some flexibility in imposing copayments, coinsurance, deductibles, and other charges on Medicaid-covered benefits. Certain groups, such as children, terminally ill individuals, and those residing in institutions, are typically exempt from out-of-pocket costs for specific services like emergency care, family planning, and pregnancy-related services.
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Dual-eligible special needs plans (D-SNPs)
Dual-eligible individuals, or "dual eligibles", are those who are enrolled in both Medicare and Medicaid. Medicare is a federal health insurance program for seniors and disabled persons, while Medicaid is a state and federal medical assistance program for financially needy persons of any age. Dual-eligible special needs plans (D-SNPs) are a type of Medicare Advantage plan designed specifically for dual-eligible individuals. These plans are offered by private insurance companies approved by Medicare, and they combine all the benefits of Medicare and Medicaid into one easy-to-manage plan.
To be eligible for a D-SNP, individuals must be enrolled in both Medicare and Medicaid. Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) are prerequisites for dual eligibility. Additionally, individuals must be enrolled in either full-coverage Medicaid or one of Medicaid's Medicare Savings Programs (MSPs). Full-coverage Medicaid covers physician visits, hospital services, laboratory services, and x-rays.
D-SNPs are required to provide greater coordination between Medicare and Medicaid benefits than other Medicare Advantage plans. They typically offer benefits not available in traditional Medicare, such as long-term services and supports, and do not charge a premium. As of 2023, most D-SNP enrollees were in coordination-only (CO) plans, which provide a minimum level of coordination between Medicare and Medicaid without being fully integrated.
D-SNPs also include Part D prescription drug coverage at no extra cost. Enrollees are assigned a care coordinator to develop a care plan to help them achieve optimal health. However, there are concerns about a lack of data transparency regarding the impact of prior authorization requirements and denials for dual-eligible individuals enrolled in D-SNPs.
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Frequently asked questions
Dual eligibility, or being a dual-eligible beneficiary, means that a person is enrolled in both Medicare and Medicaid.
To be considered dual eligible, you must be enrolled in Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance). You must also be enrolled in either full-coverage Medicaid or one of Medicaid's Medicare Savings Programs (MSPs).
Medicare is the primary source of health insurance coverage for dual-eligible individuals. Medicaid acts as supplemental coverage, paying for out-of-pocket and non-covered expenses, including Medicare premiums, copays, and coinsurance. Medicaid also covers long-term care, which Medicare does not.
As of 2023, 12.5 million Americans were enrolled in both Medicare and Medicaid.
Like all Medicare beneficiaries, dual-eligible individuals may choose to receive their Medicare benefits through traditional Medicare or a Medicare Advantage plan. This decision may impact how you receive your Medicaid benefits and the degree to which that coverage is coordinated with Medicare.
