How to Qualify for both Medicare and Medicaid (Dual Eligibility)

Medicare and Medicaid are government-run programs that both provide coverage for medical costs for individuals that qualify. But they are separate programs with different requirements. There are certain scenarios where individuals can qualify into receiving both Medicare and Medicaid coverage otherwise known as dual eligibility.

How do you qualify for Medicare?

Medicare is federally funded health insurance coverage for adults that are over age 65 and some younger individuals a qualified disability. People with end-stage renal disease will also typically qualify for Medicare.

Medicare includes Part A, which covers hospital costs. For example, Medicare Part A covers inpatient hospital costs, such as a hospital room, nursing care, and meals.

Most people receive Medicare Part A premium-free when they reach age 65. But in some cases, an individual may have to pay a premium for Medicare Part A.

According to the Centers for Medicare and Medicaid Services, individuals qualify for premium-free Medicare Part A based on paying Medicare taxes through employment. Someone may also meet eligibility through the earnings of a spouse.

Medicare also includes Part B, which covers outpatient services, such as doctor’s visits and outpatient diagnostic tests. Unlike Part A, there is a cost for Part B premiums. For more detailed information visit Original Medicare Parts A & B Eligibility.

How do you qualify for Medicaid?

Medicaid is a state-run health insurance program regulated under federal guidelines. Medicaid provides health insurance coverage to low-income adults and children.

State guidelines for eligibility may differ. You can apply for Medicaid through your state Medicaid office. To qualify for Medicaid, someone needs to meet the income requirements in their state.

Many states have expanded their Medicaid coverage to include more people. According to Healthcare.gov, if your household income falls below 133% of the federal poverty level, you likely qualify for Medicaid. Most states also have multiple Medicaid programs that some individuals may qualify based on additional factors, such as whether they are pregnant or disabled.

What does Medicaid pay for?

Medicaid pays for both hospital care, such as inpatient hospital stays, nursing care, and medication. It also pays for outpatient care, such as some diagnostic tests and doctor’s visits.

What is dual eligibility for Medicare and Medicaid?

Dual eligibility for Medicare and Medicaid means you qualify for both health insurance programs. To qualify for Medicare with Medicaid, you must meet the following:

Be eligible for Medicare based on age or a disability
Meet the income requirements for Medicaid in the state you live

Keep in mind; Medicare eligibility is the same for each state. But Medicaid eligibility may vary since each state sets its own rules within the federal guidelines. So, two people with the same income in different states may not qualify for Medicaid.

Do you need both Medicare and Medicaid?

Medicare does not typically pay 100% of all healthcare costs. In some cases, you may have a copay or coinsurance cost. Medicaid can help cover some of the costs.

If you do qualify for both Medicare and Medicaid, Medicare covers the costs first. Medicare is the primary insurance.

Medicaid may kick in after Medicare coverage. For example, if you have an outpatient procedure, which is covered by both Medicare and Medicaid, Medicare will act as the primary insurance and cover the cost. In some cases, you may have expenses, such as copays, that Medicare does not cover. It is possible Medicaid may cover these costs.

Medicaid as secondary insurance is helpful to cover more healthcare costs than just Medicare alone would. Medicaid may also cover certain expenses that Medicare does not cover, such as nursing home care.

Individuals that have dual eligibility for Medicare and Medicaid are automatically enrolled in the Extra Help Program. The extra help program assists recipients with limited income cover costs of Medicare prescription drug costs, such as coinsurance, premiums, and deductibles. Because of the additional help with coverage that Medicare may not cover, it makes sense to also utilize Medicaid if you qualify.

How does dual eligibility with A Medicare Advantage Plan work?

People that are eligible for Medicare and Medicaid can choose a Medicare Advantage plan as an option to original Medicare. In terms of which program provides the primary coverage, it is the same as with original Medicare. Your Medicare Advantage plan covers eligible costs first. Medicaid acts as the secondary insurance and covers costs after Medicare Advantage.

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