How to Dual Qualify for Medicare and Medicaid
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To qualify for both Medicare and Medicaid, you must meet the requirements of and enroll in both programs.
Most people qualify for Medicare when they turn 65, although you may qualify at a younger age if you have a disability or specific medical condition. Medicaid is generally reserved for low-income applicants, although other groups may qualify depending on a state's regulations. Being covered by both Medicare and Medicaid will lower and may eliminate your health care costs.
Can you have Medicare and Medicaid together?
You can be covered by Medicaid and Medicare at the same time.
When you're covered by both programs, Medicare and Medicaid work together to cover a considerable portion of your health care costs. Medicare always pays first for services and procedures that it covers, with Medicaid paying secondarily.
For example, you may receive a $1,000 bill for a doctor visit. Assuming you've met your deductible, Medicare Part B usually pays 80% of those costs, or $800. Medicaid may pay the additional $200, meaning you would have nothing to pay out of your own pocket.
Not everything is covered by both programs, though. You may encounter a scenario where something is covered by only Medicare, for example, and Medicaid wouldn't pay anything toward the remaining bills. If you have complex medical needs, you should review your coverage carefully to understand how your plans work together.
You can also have either full or partial dual eligibility for Medicare and Medicaid.
- Full dual eligibility means you qualify for Medicare and full Medicaid benefits.
- Partial dual eligibility means you qualify for Medicare but only for partial Medicaid benefits.
How to qualify for Medicare and Medicaid
You have to meet the federal eligibility requirements for Medicare and your state's specific Medicaid requirements to be dually eligible.
To be eligible for Medicare, you must be:
- A U.S. citizen or have permanent resident status
- Over 65
You can also qualify for Medicare if you are younger than 65 but have a disability, kidney failure (ESRD) or ALS (Lou Gehrig's disease).
Medicaid is reserved for low-income individuals and those who have specific health care needs. Federal law also mandates that certain other groups, including qualifying pregnant women, some children and those who receive Supplemental Security Income (SSI) be eligible.
While there are federal stipulations, Medicaid enrollment is handled by individual states. Each state has some freedom to change or broaden eligibility requirements, as long as the federally mandated groups are covered. The best way to find out if you qualify is to review the Medicaid qualifications in your state.
What happens if you lose your CHIP or Medicaid coverage?
The end of looser COVID-19-era eligibility requirements has caused more than 10 million people to lose their Medicaid or Children's Health Insurance Program (CHIP) coverage. If you fall into this group, you can enroll in an Affordable Care Act (ACA) marketplace plan outside of the normal open enrollment period. The enrollment window is known as a Medicaid unwinding special enrollment period.
You can take advantage of this special enrollment period within 60 days (90 days starting Jan. 2024) of losing your CHIP or Medicaid coverage. Availability varies by state.
The Medicaid unwinding special enrollment period applies to people who lose coverage between March 31, 2023, and July 31, 2024.
Medicare Savings Programs for the dually eligible
If you have partial dual eligibility, you may qualify for a Medicare Savings Program (MSP). These programs are designed to help those with low incomes pay for the cost of Medicare.
If you are part of an MSP, some or all of your monthly Medicare premiums could be paid for by Medicaid.
- The Qualified Medicare Beneficiary (QMB) Program helps pay the monthly cost for Medicare Parts A and B. It also helps with the cost of deductibles, coinsurance, copayments and prescription drugs.
- The Specified Low-Income Medicare Beneficiary (SLMB) Program helps pay for Medicare Part B, although you must have both A and B to qualify. The SLMB Program also offsets some prescription drug costs.
- The Qualifying Individual (QI) Program is similar to the SLMB Program but has a higher monthly income limit. You must reapply for this program every year.
- The Qualified Disabled Working Individual (QDWI) Program is for individuals who have a disability, are working, and lost premium-free Medicare Part A and Social Security disability benefits because of returning to work. This program helps pay the cost of Medicare Part A.
Why dual qualifying is worthwhile
One of the main benefits of having both Medicare and Medicaid is that you'll usually pay very little for your health care expenses. Dual qualifying is also beneficial because it:
- Lowers health care costs: If you're eligible for and enrolled in both Medicare and Medicaid, your health care costs could be drastically reduced and potentially even eliminated. Medicare will pay first for covered expenses and Medicaid will pick up some or all of the remaining costs based on how Medicaid covers that expense.
- Lowers monthly rates: If you qualify for an Medicare Savings Program, Medicaid could reduce some or all of your Medicare premiums, deductibles, copays and coinsurance amounts.
- Offers coordinated care: You may qualify for a Medicare dual-eligible Special Needs Plan (D-SNP) or Medicare-Medicaid Plan (MMP), depending on your state. These plans help to coordinate your Medicare and Medicaid benefits so you get the most out of your coverage.
- Offers long-term care: Medicaid offers a host of long-term care benefits that Original Medicare (Parts A and B) does not. Some Medicare Advantage plans offer long-term care benefits, but being dually eligible may broaden the scope of your coverage.
Frequently asked questions
What does dual eligibility mean?
Dual eligibility means that you qualify for both Medicare and Medicaid. Being enrolled in both programs can significantly lower and even eliminate your health care costs.
Who is eligible for both Medicare and Medicaid?
You're eligible for Medicare if you are a U.S. citizen or permanent resident age 65 or older, or if you are younger and have a qualifying disability or medical condition. Medicaid eligibility varies by state, but the program is generally reserved for low-income households and those who need certain types of medical care.
How do Medicare and Medicaid work together?
Medicare will always pay first for covered services, and Medicaid will usually pay on the remaining amount if the service is covered by Medicaid. If you're enrolled in both Medicare and Medicaid, you may also qualify for a D-SNP or an MMP, which are programs that can help you coordinate your benefits.
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