What People Get Wrong About Dual Eligibility
Dual Eligibility: what people commonly get wrong, set against what published US guidance says.
Dual-eligible people often qualify for extra help with premiums and drug costs, but the two programs' rules can be confusing.
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 speak to a doctor" below apply to you.
What the guidance actually says
These are the numbers the corrections below are measured against.
| 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 |
Where people go wrong
What people tend to think, set against what is actually published.
- 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
What to do instead
- 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
The part that is genuinely uncertain
Guidance changes, and it changes because evidence does. The figures above reflect current US guidance from the bodies named at the foot of this page; where those bodies revise their position, theirs is the account to follow rather than this one.
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
- A Q and A on Dual Eligibility
- Dual Eligibility: The Quick Reference
- Dual Eligibility — the reference entry
- 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 speak to a doctor
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.
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