Can You Have Both Medicare and Medicaid?
- Beneficiaries who are eligible for both Medicare and Medicaid are considered “dual eligible.” Learn how to enroll and the benefits you can expect if you qualify for dual eligibility.
As of 2019, well over 12 million Americans are dual eligible for both Medicare and Medicaid. You may wonder how someone can have both Medicare and Medicaid, and you may wonder if you qualify for dual eligibility.
Below we’ll discuss the eligibility qualifications for Medicare and Medicaid, the benefits available to you if you’re dual eligible and other information you may want to know about dual eligibility.
How Do You Qualify for Dual Eligibility?
To be “dual eligible” means to be eligible for Medicare Part A and/or Part B along with full Medicaid benefits and/or assistance. Being dual eligible and enrolling in Medicare and Medicaid means you typically get assistance with Medicare costs such as premiums, coinsurance and deductibles through a Medicare Savings Program (see below for more information about Medicare Savings Programs, or MSPs).
Income Tiers for Dual Eligibility
Each state sets its own income limits for Medicaid eligibility. Thus, the income tiers for dual eligibility will also vary from state to state.
A reasonable benchmark to use for Medicaid eligibility in 2021 is 138% of the federal poverty level. The federal poverty level is a measure of annual income issued every year by the Department of Health and Human Services to determine eligibility for Medicaid and certain other assistance programs.
For 2021, the federal poverty level for the continental 48 states and the District of Columbia is:
- $12,880 for individuals
- $17,420 for a family of 2
- $21,960 for a family of 3
- $26,500 for a family of 4
- $31,040 for a family of 5
- $35,580 for a family of 6
- $40,120 for a family of 7
- $44,660 for a family of 8
Federal poverty levels differ in Alaska and Hawaii.
Most states use an income of no more than 138% of the federal poverty level in order to be eligible for Medicaid. For example, a family of 3 in Arizona would need a household income of no more than $30,304.80 (138% of $21,960) in order to be eligible for Medicaid.
If a member of that family is also eligible for Medicare because of their age or a disability, they would be dual eligible.
Some states have different income tiers for families and individuals. You can explore a complete online list of state income tiers for Medicaid eligibility.
Dual eligibility can be split out into full and partial eligibility. Those who qualify for full dual eligibility typically receive Supplemental Security Income (SSI), which provides financial assistance to people who are aged, blind or disabled. In 2020, the maximum income for SSI eligibility is $783 per month for an individual and $1,175 for a married couple.
If someone is “partial dual eligible,” they may receive financial assistance for certain Medicare costs from their state Medicaid program through a Medicare Savings Program. However, they do not qualify for full Medicaid benefits and are not “fully dual eligible.”
Like full Medicaid eligibility, income limits for partial eligibility vary by state. If one makes more money than the income limits for full Medicaid benefits but are still within the income limits required for a Medicare Savings Program, they will typically qualify for partial eligibility.
Who Is Eligible for Medicare?
Medicare is a federally-run health insurance program for people age 65 and over and people under the age of 65 who have a qualifying disability. Original Medicare, which is proved by the federal government, consists of Medicare Part A hospital insurance and Medicare Part B medical insurance.
To be eligible for Medicare, you must meet the following Medicare eligibility requirements:
- You are at least 65 years old and are eligible for retirement benefits from Social Security or the Railroad Retirement Board, OR you are under 65 and are eligible for disability benefits from Social Security or the Railroad Retirement Board. You can also qualify if you have Lou Gehrig’s disease (ALS) or permanent kidney failure (End-Stage Renal Disease, or ESRD).
- You are a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years.
You may also be eligible for Medicare if you or your spouse is a current or former government employee who has paid Medicare taxes while working.
If you do not qualify for retirement or disability benefits, you may still be eligible for Medicare at age 65, but you may have to pay a monthly premium for Medicare Part A.
Who Is Eligible for Medicaid?
Medicaid is a health insurance program that is jointly operated by federal and state governments and provides coverage for individuals and families who have low incomes or limited financial resources.
Because each state administers its own Medicaid program, eligibility criteria can vary by state. Medicaid eligibility generally depends on your income, family size and state. You may use this tool from HealthCare.gov to help determine your Medicaid eligibility.
Dual Eligibility: How Medicare and Medicaid Work Together
If you are dual eligible and visit a health care provider who accepts both Medicare and Medicaid, Medicare will be the primary payer and Medicaid will be the secondary payer.
This means Medicare will pay its share of your health care costs first. As the secondary payer, Medicaid can help pay for the out-of-pocket costs Medicare doesn’t cover, such as your coinsurance, copayment and deductible costs. This combination of insurance payers means you pay little to nothing for your covered health care services.
If you are enrolled in a Medicare Savings Program (MSP), you may also receive help paying for your Medicare premiums and deductibles.
Dual eligible beneficiaries are also automatically eligible for the Medicare Extra Help program, which helps pay for prescription drug costs (see below for more information on Extra Help).
What Is a Medicare Savings Program?
Most dual eligible beneficiaries are also eligible for a Medicare Savings Program (MSP), which provide cost assistance for Medicare Part A and Part B premiums, deductibles, coinsurance and copayments.
There are four types of Medicare Savings Programs.
- Qualified Medicare Beneficiary (QMB)
This program covers Medicare Part A premiums and Part B deductibles, copayments and coinsurance. The monthly income limits for eligibility in 2020 are $1,084 for individuals and $1,457 for married couples. The financial resource limits are $7,860 for individuals and $11,800 for married couples.
- Specified Low-Income Beneficiary (SLMB)
This MSP helps pay for Medicare Part B premiums. Individuals with monthly income of less than $1,296 and financial resources of no more than $7,860 are eligible for the SLMB in 2020. Married couples with monthly incomes of $1,744 or less and resources of no more than $11,800 are also eligible.
- Qualifying Individual (QI)
The Qualifying Individual program pays for the Medicare Part B premium. To be eligible, individuals must have income of less than $1,456 per month in 2020 and resources of no more than $7,860. Eligible married couples can have income up to $1,960 per month and resources of up to $11,800.
- Qualified Disabled Working Individual (QDWI)
The QDWI program pays for the Medicare Part A premium for people age 65 and under who qualify for Medicare due to a disability, or people who are 65 and older who meet other eligibility requirements. Individuals must have a monthly income of no more than $4,339 per month to qualify in 2020, and married couples must have monthly incomes of less than $5,833. The financial resource limits for eligibility are $4,000 for individuals and $6,000 for couples.
What Is Medicare Extra Help?
Extra Help is a program that helps Medicare beneficiaries pay for Medicare Part D Prescription Drug plan premiums, deductibles and coinsurance. Medicare Part D plans are sold by private insurance companies and provide coverage for prescription drugs, but they are subject to some federal regulation.
Anyone who is dual eligible for Medicare and Medicaid is also eligible for Medicare Extra Help. Anyone enrolled in a Medicare Savings Program is automatically enrolled in Extra Help. Extra Help is also known as the Part D Low-Income Subsidy (LIS).
Benefits of the Extra Help program include:
- Covering the cost of Medicare Part D premiums
- Lowering the cost of prescription drugs
- Allowing for Special Enrollment Periods to enroll in a Part D plan or to switch between Medicare prescription drug plans
- Eliminating any Part D late enrollment penalties you may have incurred
What Is a Dual-Eligible Medicare Advantage Special Needs Plan (D-SNP)?
Dual-eligible beneficiaries are also eligible for a certain type of Medicare Advantage plan called a Dual-Eligible Special Needs Plan (DSNP).
Medicare Advantage plans, also known as Medicare Part C, are sold by private insurers. By law, they must provide all of the same basic coverage as Medicare Part A and Part B. Medicare Advantage plans may also offer additional benefits that Original Medicare doesn’t cover, such as coverage for dental, vision, hearing aids, prescription drugs and more.
A Special Needs Plan (SNP) is a specific type of Medicare Advantage plan that is designed for beneficiaries who have certain health conditions or financial circumstances. A Dual-Eligible Special Needs Plan (D-SNP) contains coverage that is tailored for someone with low income and resources. Prescription drug coverage is automatically a part of D-SNPs.
You can browse Medicare plans online and compare any Medicare-Medicaid D-SNP plans that may be available where you live.
Medicaid Managed Care Programs
In some states, health care services are delivered to dual eligible beneficiaries through a Medicaid managed care program, which are similar to Medicare Advantage plans. These programs provide care under a contract with the state, and they pay health care providers directly for their services.
Learn More About Dual Eligibility
If you have any questions pertaining to your eligibility or benefits under Medicare or Medicaid, you may consult the following:
- Contact Medicare at 1-800-MEDICARE (1-800-633-427)
- Contact your state Medicaid agency
- Contact your State Health Insurance Assistance Program (SHIP)
What Is PACE?
The Program of All-Inclusive Care for the Elderly (PACE) is a program for older Medicare and Medicaid beneficiaries that allows people to meet their health care needs within the community instead of in a nursing home or other care facility.
PACE uses a team of health care professionals that coordinate your care including prescriptions, doctor appointments, hospital visits and even transportation. There are no deductibles or copayments in PACE and the program covers everything included under Medicare and Medicaid if authorized by the person’s health care team.
Qualifying for PACE requires being at least 55 years of age, living in an area serviced by PACE, require a nursing-home level of care and able to live safely in the community with assistance from PACE.
You can search online to find PACE programs in your area.