How Does My Coverage Change If I’m Dual Eligible?
Key Takeaways
- Dual-eligible beneficiaries are individuals who receive both Medicare and Medicaid benefits.
- The two programs cover many of the same services, but Medicare pays first for the Medicare-covered services that are also covered by Medicaid.
- Medicaid covers services that Medicare does not cover.
How Does Dual Medicare and Medicaid Coverage Work?
Dual coverage sounds complicated, but you typically receive your benefits through each program. For Medicare benefits, Original MedicareOriginal Medicare is a fee-for-service health insurance program available to Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). or Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). administered by the Centers for Medicare and Medicaid Services (CMS) or a Managed Care provider have oversight with Medicaid. For Medicaid benefits, a dual enrollee will enroll in their state’s Medicaid program. Medicare is the primary payer for most services, but Medicaid covers benefits not offered by Medicare.
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What’s Covered?
Your Medicare coverage does not vary with dual enrollment, but Medicaid categories and programs vary based on income, and may impose restrictions. There are several Medicare Savings Programs, including:
- Qualified Medicare Beneficiary (QMB) program: supports the payment of Medicare Part A and Part B premiums.
- Specified Low-Income Medicare Beneficiary (SLMB) program: supports the payment of Part B premiums for individuals with an income greater than 100% but less than 120% of the Federal Poverty Level
- Pharmacy: Medicare Part D covers premiums deductibles, and other prescription drugs for all Dual-eligible beneficiaries.
For some dual eligible groups, Medicaid can cover some or all of the following:
- Medicare Part A premiums
- Medicare Part B premiums
- Co-insuranceCoinsurance is the percentage of your medical costs that you pay after you meet your deductible. Your insurance company pays the remaining amount. For example: If you have a $1,000 medical bill and your coinsurance is 20%, you’ll pay $200. Your insurance company will cover the final $800. under Part A or Part B
- Full Medicaid Coverage
Dual Eligible Special Needs Plans
A Dual Eligible Special Needs Plan (D-SNP) is a type of Medicare Advantage (Part C) plan offered by private insurance carriers specifically for dual eligible beneficiaries.
D-SNPs must at least match the coverage you would get under Original Medicare and include Part D prescription drug coverage. They may also provide a range of additional benefits.
Can I Change Plans?
When you become eligible for Medicare and Medicaid, you have a special enrollment period. The enrollment period begins with your eligibility and ends two months after losing Medicaid. Your coverage begins on the first day of the following month.
As of 2025, fully dual-eligible beneficiaries can use a monthly Special Enrollment Period to join certain D-SNPs. Reach out to an insurance carrier or a licensed insurance agent for more information about the D-SNPs available in your area.
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If I have Medicare, how do I know if I’m eligible for Medicaid?
If I want to discuss my coverage, do I have to contact both Medicare and Medicaid?
Medicare and Medicaid do not work together directly. You can always contact your regional Medicare office. Regional Medicare offices work closely with state Medicaid agencies.
Sources
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