Dual Eligibility

Key takeaways

• Who pays first: Medicare pays first; Medicaid pays after other coverage
• Drug costs: dual-eligible people automatically qualify for Extra Help
• Most useful single change: Show both your Medicare and Medicaid cards at every visit.
• Commonest mistake: Paying a bill for Medicare cost-sharing if you are in the QMB program; tell the provider instead.
• See a doctor if any of the signs under "When to get help" below apply to you.

Why it matters

Dual-eligible people often qualify for extra help with premiums and drug costs, but the two programs' rules can be confusing.

The numbers, in one place

Published figures for Dual Eligibility

Measure	Figure
Who pays first	Medicare pays first; Medicaid pays after other coverage
Drug costs	dual-eligible people automatically qualify for Extra Help
Medicare Savings Programs	state programs that can help pay Medicare premiums and, for some, deductibles and coinsurance
QMB program	providers are not allowed to bill people in the Qualified Medicare Beneficiary program for Medicare cost-sharing
Special plans	Dual Eligible Special Needs Plans coordinate Medicare and Medicaid benefits

What helps

• Show both your Medicare and Medicaid cards at every visit
• Apply for a Medicare Savings Program through your state Medicaid agency
• Ask your State Health Insurance Assistance Program (SHIP) whether a special needs plan suits you
• Keep renewal paperwork up to date for both programs

What to avoid

• Paying a bill for Medicare cost-sharing if you are in the QMB program; tell the provider instead
• Assuming you must stay in a plan that is not working for you; plan change rules differ for dual-eligible people
• Ignoring Medicaid renewal notices

In depth

People who qualify for both Medicare and Medicaid are often called dual-eligible. Medicare is their main health insurance, covering hospital care, doctor visits and prescriptions through Part D. Medicaid then fills in, helping with Medicare premiums and cost-sharing and covering services Medicare does not, such as long-term care at home or in a nursing home and, in many states, some dental, vision or transportation services.

Not everyone with both programs gets the same help. People with "full" Medicaid qualify for their state's full set of Medicaid benefits as well as help with Medicare costs. Others qualify only for a Medicare Savings Program, a narrower form of Medicaid that helps pay Medicare premiums and, for some people, deductibles and coinsurance. Knowing which group you are in tells you what to expect when you get care.

The main challenge for dual-eligible people is coordination. Two programs with different rules, cards, notices and renewal dates can be confusing, and providers sometimes bill incorrectly. Integrated plans, called Dual Eligible Special Needs Plans, try to bring Medicare and Medicaid benefits together under one plan and one care coordinator. They can simplify things, but they are not right for everyone.

Signs and symptoms

• Receiving letters from both Medicare and your state Medicaid agency
• Being charged copays or coinsurance that you thought Medicaid should cover
• Getting a notice that you automatically qualify for Extra Help
• Needing help at home with bathing, dressing or meals
• Paying a Part B premium that takes a large share of your monthly income

Causes and risk factors

• Having Medicare and limited income and resources
• Receiving Supplemental Security Income, which usually brings Medicaid
• Needing long-term care that uses up income and savings
• Living in a state with more generous Medicaid or Medicare Savings Program rules
• Disability that qualifies you for Medicare before 65, combined with low income

How it is checked

To find out whether you are dual-eligible, apply for Medicaid or a Medicare Savings Program through your state Medicaid agency. Some states set income and asset limits higher than the federal minimum, and some have removed asset tests for Medicare Savings Programs. A SHIP counselor can help you apply and work out which programs you might qualify for.

Once approved, your notice should say which program you have. If you are in the Qualified Medicare Beneficiary program, providers cannot bill you for Medicare deductibles, coinsurance or copays. Your Medicare Summary Notice or plan statements should show that you owe nothing for covered services. If they do not, contact 1-800-MEDICARE.

Related topics

• Premiums, Deductibles and Copays: What the Evidence Actually Says (Health Insurance and Costs)
• What the Guidance Really Says About Benefits and Financial Support (Long-Term Conditions)
• Annual Wellness Visit: What the Evidence Actually Says (Preventive Care)
• The Evidence on Travel Insurance and Healthcare Abroad, Without the Hype (Travel Health)

Where to go next

• Dual Eligibility: The Practical To-Do List
• What People Get Wrong About Dual Eligibility
• Medicare and Medicaid: The Complete Guide
• Medicare and Medicaid Appeals: What the Evidence Actually Says
• Original Medicare (Parts A and B): What Published Guidance Supports

When to get help

If a provider bills you and you think you are protected, call 1-800-MEDICARE (1-800-633-4227) before paying. Call 911 for any medical emergency.

Where this comes from

• CMS — Dual Eligible Beneficiaries under Medicare and Medicaid
• Medicare.gov — Medicare Savings Programs

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.