Dual-Eligible

What is a Dual-Eligible Person?

Dual-eligible individuals are those who receive both Medicare and Medicaid benefits. It includes beneficiaries enrolled in Medicare Part A and/or Part B while receiving full Medicaid and/or financial assistance through a Medicare Savings Program.

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• Dual-eligible beneficiaries are those who qualify for both Medicare and Medicaid.
• When dually eligible, Medicare is the primary payer for all Medicare-approved healthcare services, while Medicaid or a Medicare Savings Program helps with the remaining out-of-pocket costs.
• When available, dual-eligible beneficiaries can join a Medicare Advantage Special Needs Plan.

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What is Covered for a Dual-Eligible Beneficiary?

The level of coverage for a dual-eligible beneficiary depends on whether they are a full benefit or partial benefit dual-eligible. Full benefit dual-eligible are enrolled in both Medicare and Medicaid. These programs work together to provide health care coverage, assistance with Medicare premiums and costs, and coverage for services that are not covered by Medicare alone, such as dental care, hearing care, and nursing homes.[mfn referencenumber=1]Medicare.gov, “Medicaid“, Accessed October 26, 2021[/mfn]

Partial benefit dual-eligibles are enrolled in Medicare and a Medicare Savings Program. Medicare provides health care coverage for these beneficiaries while the Medicare Savings Programs would provide cost-sharing for remaining Medicare expenses.[mfn referencenumber=2]Medicare.gov, “Medicare Savings Programs“, Accessed October 26, 2021[/mfn]

What Is Medicare?

Medicare is health insurance for adults of age 65 and over, as well as people with certain disabilities. Medicare pays for approximately 80 percent of the beneficiary’s costs for medically necessary services. If beneficiaries cannot afford Medicare’s premiums, copayments, and coinsurances, then they can apply for Medicaid through their local Medicaid office.[mfn referencenumber=3]Medicare.gov, “Medicare costs at a glance“, Accessed October 26, 2021[/mfn]

What Is Medicaid?

Medicaid is a combined state and federal program that provides healthcare for families and individuals whose annual income is at or below the federal poverty level. For Medicare beneficiaries, Medicaid works in conjunction with Medicare to help pay a beneficiaries out-of-pocket costs, including monthly premiums, deductibles, and copayments. Dually-eligible beneficiaries pay minimal copayments. In some states, Medicaid also provides coverage for routine care that Medicare does not cover, including routine dental, vision, and hearing.[mfn referencenumber=1]Medicare.gov, “Medicaid“, Accessed October 26, 2021[/mfn]

Medicare Savings Program

Beneficiaries with an income level that is near the federal poverty line (FPL), under 200 percent of the FPL, but not below it can be partially dual-eligible when enrolled in Medicare and a Medicare Savings Program. Medicare Savings Programs include the Qualified Medicare Beneficiary (QMB) program, Specified Low-Income Medicare Beneficiary (SLMB) program, Qualifying Individual (QI) program, and Qualified Disabled and Working Individuals (QDWI) program. These savings programs provide assistance with Medicare premiums and cost-sharing with Medicare’s out-of-pocket costs.[mfn referencenumber=4]CMS.gov, “Dually Eligible Beneficiaries Under Medicare and Medicaid“, Accessed October 15, 2021[/mfn]

Medicare Advantage Special Needs Plans

Dual-eligible beneficiaries are also eligible to join a Medicare Advantage Special Needs Plan (D-SNP), where available. Medicare Advantage SNP plans are coordinated care plans that handle coordinating costs between Medicare and Medicaid. All D-SNP plans include prescription drug coverage and have minimal out-of-pocket costs.[mfn referencenumber=5]CMS.gov, “Dual Eligible Special Needs Plans (D-SNPs)“, Accessed October 15, 2021[/mfn]