What to Know About Dual Eligibility for Medicare & Medicaid


Despite their similarities, Medicare and Medicaid are two distinct systems. One is designed to serve the aged and disabled, while the other serves low-income individuals and families. Both programs are open to 12 million Americans. However, is it possible for someone to be dual-eligible?

Dual-eligible beneficiaries are eligible for both the programs, Medicare and Medicaid. Understanding how the programs interact can help you get the most out of your medical care. Continue reading to know everything about the dual-eligibility of Medicaid and Medicare.


Medicaid is a health care insurance program that gives financial help to low-income or low-resource people and families.

Individual states are responsible for running Medicaid programs, and the federal government establishes the rules and regulations.

Medicaid is available to everyone. Children, families, pregnant women, people with disabilities, and the elderly can also be covered under Medicaid programs. 


Medicare is a health-insurance program for adults 65 and older and those with certain medical conditions.

A person must fulfill qualifying standards based on their own or spouse’s job history to be eligible for Medicare. With Medicare, beneficiaries can qualify for free hospitalization but pay a premium for medical and prescription medication coverage.

To be qualified for Medicare, a person doesn’t need to fulfill any income-related criteria.

Dual Eligibility Criteria

You must be 65 years old (or more) or have a qualifying disability to be eligible for Medicare. You must also fulfill U.S. citizenship or permanent legal status requirements to qualify for Medicare.

On the other hand, Medicaid eligibility varies depending on where you live. Although the federal government establishes the program’s minimum standards, the states manage the program. Each state has the authority to change its qualifying requirements.

Medicaid provides health care to low-income people in various categories, including children, pregnant women, parents, elders, and people with disabilities. Adults without children might be insured under the Affordable Care Act if their state accepts the requirements of Medicaid Expansion.

It’s possible that, based on your income and assets, you’re qualified for Medicaid assistance. Another approach to fulfill the Medicaid eligibility requirements is to apply for one of the Medicare Savings Programs provided by your local Medicaid office. You may be dual-eligible if you are eligible for Medicare and fulfill the requirements for Medicaid or one of the four programs listed below.

  • Qualified Medicare Beneficiary (QMB) Program
  • Specified Low-Income Medicare Beneficiary (SLMB) Program
  • Qualifying Individual (QI) Program
  • Qualified Disabled Working Individual (QDWI) Program

Prescription Drugs Costs

To receive prescription drug coverage, Medicaid requires you to enroll in a Medicare Part D plan or a Medicare Part C plan with prescription drug benefits, often known as an MA-PD plan.

You must enroll in Original Medicare (Parts A and B) and Part D, not a Medicare Advantage plan, if you are eligible for the Extra Help program, a low-income subsidy for prescription medication benefits. Medicaid can cover some drugs that aren’t covered by your Medicare plan.

Nursing Home Costs

Millions of elderly suffer from dementia and other chronic illnesses, rendering them physically unable to care for themselves. As a result, nursing home care is a service that many individuals require.

While Medicare covers brief stays in skilled nursing facilities following a hospitalization, it does not cover long-term nursing care. Your Part A benefits will cover all nursing home expenditures for up to 20 days after qualifying hospital stays in 2022. You will pay a $194.50 per day copayment for days 21 to 100, and the total amount for nursing homes stays longer than that.

Unlike Medicare, Medicaid pays for long-term nursing home care. Dual-eligible individuals may utilize Medicaid to pay for long-term nursing facility care. Medicaid covers as much as two-thirds of nursing homestays. Unfortunately, very few people can afford to pay for their nursing home care. A shared room in a nursing home will cost $7,756 per month on average. On the other hand, a private room costs $8,821 per month.

Health Services Not Covered by Medicare

Medicare isn’t a one-size-fits-all solution. Original Medicare (Medicare Parts A and B) do not cover dental, hearing, or vision screenings. As a result, beneficiaries struggle to find dentures, hearing aids, or corrective lenses (contact lenses or eyeglasses). People who join Medicare Advantage (Medicare Part C) may select a plan that includes these services.

If these services are available via your state’s Medicaid program, you may be able to take advantage of them. However, not all states will provide coverage, and even if they do, it may not be available to everyone who meets the Medicaid eligibility requirements.

Paying for Your Health Care

In most cases, Medicare pays first, followed by Medicaid. It is because Medicaid frequently covers costs that Medicaid does not cover. On the other hand, Medicaid payments are subject to a cap imposed by each state.

If you qualify, Medicare Savings Programs might assist in offsetting additional costs.

Medicaid will cover your Medicare costs, including Part A and Part B premiums, deductibles, coinsurance, and copayments if you qualify for the QMB program. It is true even if Medicaid doesn’t cover a Medicare treatment or if you visit a healthcare provider that doesn’t take Medicaid.

Those who qualify for additional Medicare Savings Programs cut their out-of-pocket expenditures as well, although their advantages are not as substantial.


Medicare is controlled by the federal government, whereas the states administer Medicaid. Even though they are two separate programs, millions of individuals are eligible for both. When you combine these products, you may be able to lower your overall out-of-pocket healthcare expenditures, lower the cost of long-term nursing home care, and expand the number of treatments covered.

If your medical needs don’t fit the Medicare and Medicaid provided services, you can schedule a call with us, and we will suggest a suitable plan that matches your medical needs. Contact our licensed agents specializing in Medicare now!

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