Dual eligibility: What’s it all about?

You may be able to qualify for both Medicaid and Medicare, something known as dual eligibility. Here’s some information to help you understand.

1. What is Medicare?
2. What is Medicaid?

3. What’s the difference between Medicare and Medicaid?
4. Can I be eligible for both Medicare and Medicaid?
5. What’s a D-SNP, exactly?
6. What is partial dual eligibility?
7. How does a D-SNP work?
8. Could I also be eligible for more than one SNP?
9. Do I need to apply each year for my dual eligibility?

It’s easy to get confused between Medicare and Medicaid. After all, both are government-run health care programs. But there are key differences between the 2 types of health benefits.

Medicare is run by the federal government. It provides health insurance to anyone ages 65 and older, or those with end-stage renal disease or certain younger people with disabilities.

Medicaid, on the other hand, is a joint federal and state program. It provides health coverage to people of all ages with limited income or disabilities.

But you can be eligible for both. This is known as dual eligibility. Here’s a closer look at what dual eligibility is, who qualifies and the benefits of these programs.

Searching for a Medicare plan? Call a licensed insurance agent at (800) 827-9990 8 A.M to 8 P.M. M-F ET to talk about plans, or browse your options online today.

What is Medicare?

Medicare is made up of different parts. The 2 most common parts are A and B, which can also be paired with Part D. (You might also see Medicare Parts A and B referred to as “Original Medicare.”)

Medicare Part A is hospital insurance. It generally covers the following:

• Home health care
• Hospice care
• Inpatient hospital care
• Nursing home care
• Skilled nursing facility care

Medicare Part B is medical insurance. It covers medically necessary services, such as doctor visits and lab tests. It also covers preventive care. For example, it includes certain shots and screening tests.

Other things Part B covers include:

• Ambulance services
• Clinical research
• Durable medical equipment, such as walkers, oxygen equipment and infusion pumps
• Mental health treatment
• Very rarely, Part B may also cover prescription drugs. For example, it may cover certain Alzheimer’s medications or osteoporosis injections.

Medicare Part D covers prescription drugs. If you have Original Medicare, you’ll need to buy a separate prescription drug policy if you want help paying for your prescriptions.

If you have a Medicare Advantage plan, also known as Medicare Part C, a prescription plan may be included in your policy. (Medicare Advantage plans are offered through private companies and, at minimum, must provide the same coverage as Original Medicare.)

There are some things Original Medicare doesn’t cover. For example, Original Medicare doesn’t cover routine vision care, most dental care or hearing aids. These may be included in a Medicare Advantage plans offered by private insurance companies like Humana or UnitedHealthcare.

Thinking about switching your Medicare plan? Call a licensed insurance agent at (800) 827-9990 to talk about plans, or browse your options online today.

What is Medicaid?

Medicaid provides health coverage to more than 78 million Americans. This includes low-income older adults and people with disabilities. States set up and administer their own Medicaid programs. But they still must provide certain services like:

• Doctor visits
• Home health services
• Inpatient and outpatient hospital services
• Laboratory services

What’s the difference between Medicare and Medicaid?

The main difference is that Medicaid is entirely income and asset based, says Michelle Katz, M.S.N., L.P.N., a health care consumer advocate in Washington, D.C. “You need to meet certain criteria to qualify for Medicaid in your state. This is unlike Medicare, which you automatically qualify for when you turn 65,” explains Katz.

This means, in most cases, you need to be a U.S. resident, U.S. citizen or permanent legal resident for at least 5 years, as well as meet a certain low-income level, to justify assistance, says Katz. This may vary from state to state, she points out.

Can I be eligible for both Medicare and Medicaid?

The simple answer is yes, you can be eligible for both Medicare and Medicaid. In fact, there are 12 million Americans who are enrolled in both Medicare and Medicaid. Here are what the eligibility requirements might look like:

You’re eligible for Medicare if you’re over the age of 65, or if you have one of the following conditions:

• A disability
• End-stage renal (kidney) disease. This is permanent kidney failure that requires dialysis or a transplant.
• ALS (also known as Lou Gehrig’s disease)

You’re eligible for Medicaid if your income is at the federal poverty level. For 2024, this is $15,060 for an individual and $20,440 for a married couple. If you meet these criteria, you’re fully eligible for Medicaid in all states.

Some states, however, allow you to qualify for Medicaid coverage if your household income is 138% below the federal poverty level. For 2024, that’s $20,783 for 1 adult and $28,207 for a 2-person household.

Forty states in total, and Washington, D.C., have adopted this Medicaid expansion. Ten states have not adopted this Medicaid expansion. These include:

• Alabama
• Florida
• Georgia
• Kansas
• Mississippi
• South Carolina
• Tennessee
• Texas
• Wisconsin
• Wyoming

These states generally require your income to be below the federal poverty level in order to qualify.

You can also become partially eligible for Medicaid, notes Katz. This means that you qualify for a Medicare Savings Program (MSP). This is managed by the state’s Medicaid program. MSPs cover certain costs, like Part A or Part B premiums (monthly bills). But they don’t provide full Medicaid benefits.

What’s a D-SNP, exactly?

Dual Eligible Special Needs Plans, or D-SNPs, combine the benefits of Medicare with Medicaid. To enroll in a D-SNP, you’ll first need to enroll in Original Medicare.

If you’re already enrolled in Medicaid, you’ll automatically become eligible for a D-SNP, notes Adria Gross, president of MedWise Insurance Advocacy in Monroe, New York. If you’re not, then you’ll need to apply. You can apply through your state’s Medicaid agency.

Finally, there’s 1 more step: You need to live in a D-SNP service area. Each year, different types of Medicare D-SNP plans are available in different parts of the country. Insurance companies may also offer more than one plan in an area, with different benefits.

Some ways to find a Medicare D-SNP in your area are:

• Look at the “Medicare & You” handbook that’s mailed to you each year. It lists Medicare SNPs in your area.
• Visit the government’s Medicare website.
• Call a licensed insurance agent at (800) 827-9990.

What is partial dual eligibility?

If you qualify for both Medicare and Medicaid, you’re known as dual eligible, says Katz. But some people don’t have an income that’s low enough to make them eligible for Medicaid. In that case, they may be able to get partial dual eligibility.

There are 4 main categories of partial dual eligibility:

• Qualified Medicare Beneficiary (QMB). The QMB helps to pay premiums for Medicare Parts A and B, copays, deductibles and coinsurance.
• Specified Low-Income Medicare Beneficiary (SLMB). This helps with Medicare Part B premiums only.

• Qualified Individual (QI) programs help pay premiums for Medicare Part B members with higher incomes than with SLMB.

• Qualified Disabled and Working Individuals (QDWI). This is for people who are disabled but have returned to work. These people have lost their premium-free Part A coverage. QDWI helps to pay these premiums.

If you have partial dual eligibility, you can get some Medicaid services through MSPs. You can apply for MSPs through your state.
“When you apply, your state determines which program or programs you qualify for,” says Gross. “Even if you don’t think you quite qualify, you should still apply.”
This is true even if your income or resources are slightly higher than the state limits. That’s because some states only count certain types or specific amounts of income or resources, so you may be eligible.

Thinking about a new Medicare plan? Call a licensed insurance agent at (800) 827-9990 to talk about plans, or browse your options online today.

How does a D-SNP work?

“A D-SNP is the best of both worlds. It coordinates your Medicare and Medicaid benefits,” says Katz. “The goal is to make your medical care better and more efficient.” Here are some of the advantages if you have a D-SNP:

• D-SNPs usually offer the most comprehensive set of health benefits of all the Medicare plans. They also often have a care coordinator. This coordinator can let you know what your benefits are. They can also let you know who gets the differences in Medicaid and Medicare coverage, says Katz.
• D-SNPs are easier to navigate than other Medicare plans. This is thanks to a service team who understands the differences in Medicaid and Medicare coverage. You’ll also have a personal care team to help coordinate services for your own unique health needs. “They can also help you find in-network doctors or schedule appointments. They can also help you arrange for transportation or meal delivery for eligible individuals with certain health conditions or certain disabilities requiring meal assistance,” notes Katz.
• D-SNPs offer extra benefits beyond what you’ll get from Original Medicare and Medicaid.
• D-SNPs have minimal, if any, out-of-pocket health care costs. Medicare pays its portion first. Then Medicaid pays any remaining costs.

Could I also be eligible for more than one SNP?

Yes. There are 2 other types of SNPs. They are:

Chronic condition SNP (C-SNP). People need at least 1 of these chronic conditions to qualify:

• Alcohol or other drug dependence
• Cancer
• Certain autoimmune disorders, such as rheumatoid arthritis or lupus
• Certain chronic lung diseases, such as asthma, chronic bronchitis or emphysema
• Certain forms of heart disease
• Certain neurological disorders, such as epilepsy or Parkinson’s disease
• Chronic heart failure
• Dementia
• Diabetes
• End-stage kidney or liver disease
• HIV/AIDS
• Mental health conditions such as bipolar disorder or schizophrenia
• Some blood diseases
• Stroke

You usually need a verification letter from your medical provider to be eligible. C-SNP members usually have access to a group of medical providers who specialize in their condition. They may have better coverage for prescription drugs that are used to treat their condition.

Institutional SNP (I-SNP). This is for people who live in the community but need long-term care at a facility such as a:

• Intermediate care facility
• Long-term care hospital
• Nursing home
• Psychiatric hospital
• Rehabilitation hospital
• Skilled nursing facility
• Swing-bed hospital (a type of hospital that can use its beds, as needed, for skilled nursing facility care)

You usually qualify for more than one SNP if you have a chronic condition. You may also qualify if you’re low income and live in a nursing home.

In general, if you have a choice between 2 SNPs, a D-SNP may be your best option. They tend to offer the most comprehensive health benefits, says Katz. These include monthly credits to spend on healthy food, certain over-the-counter products and utility bills.

Do I need to apply each year for my dual eligibility?

Yes. Your state will have you undergo something called Medicaid redetermination. This is when they check to make sure that you’re still eligible, explains Gross.

If you’re enrolled in a D-SNP and you lose your Medicaid eligibility, your plan will usually put you on hold for 6 months. You’ll still have insurance. But you’ll have to pay the Medicare cost-sharing portion. This includes copayments, coinsurance, deductibles and premiums. If you don’t regain your Medicaid eligibility at the end of the 6 months, you’ll be unenrolled from the dual plan.

The good news is that you can enroll in a dual plan at any time. That means that if you become eligible for Medicaid again, you can just re-enroll.

Have additional coverage questions? Call a licensed insurance agent at (800) 827-9990 to talk about plans, or browse your options online today.