Medicaid and Medicare each have their own rules for eligibility, which can even include qualifying for both. Here’s what to know.

It’s easy to feel confused when navigating the rules of Medicare and Medicaid. Both are government-run health care programs.

Medicare is run by the federal government and offers health insurance to anyone ages 65 and older, as well as some younger people with disabilities and people with end-stage renal disease (ESRD) and/or ALS (also called Lou Gehrig’s disease). Medicaid, on the other hand, is a joint federal and state program that provides health coverage to people with limited income and disabilities.

While you might think you can only be enrolled in one or the other, you may actually be eligible for both. Here’s a closer look at who qualifies for dual eligibility, and why.

Got questions? Get more details now, or call a licensed insurance agent at 1-844-211-7730 to discuss your options.

What is the difference between Medicare and Medicaid?

Usually, to qualify for Medicare in your state of residence, you need to be at least 65 years old and be a naturalized American citizen or permanent legal resident for at least 5 years, says Adria Gross. She’s the president of MedWise Insurance Advocacy in Monroe, New York. You can also receive Medicare if you are 64 or younger and meet the following conditions:

• You’ve been receiving disability benefits from Social Security for at least 2 years
• You have ESRD
• You have Lou Gehrig’s disease

Medicaid, on the other hand, is almost entirely based on your income and assets. So that would be anything of value that you own, such as property, notes Gross. You’ll need to meet a certain low-income level — which varies, depending on your state — to be able to get assistance. According to the Kaiser Family Foundation, 87% of people who received both Medicaid and Medicare lived on an income of less than $20,000 a year.

Can you qualify for both Medicare and Medicaid?

The simple answer is yes. For someone to qualify for both Medicare and Medicaid, you have to already be able to get Medicare and also meet a certain low-income threshold, explains Michelle Katz, a health care advocate based in Washington, D.C.

Usually, you’re enrolled in one and then become eligible for the other. If you’re not sure if you can receive both, Gross recommends that you check with your state’s Medicaid office to see what the income limits are for eligibility.

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What is partial dual eligibility?

When you qualify for both Medicare and Medicaid, it’s known as being dual eligible. But sometimes, your income may not be quite low enough to be eligible for Medicaid. In that case, you may be able to get partial dual eligibility. There are 4 main categories for partial coverage:

1. Qualified Medicare Beneficiary (QMB). The QMB helps to pay monthly insurance bills (premiums) for Medicare Part A (hospital insurance) and Part B (medical insurance), and it provides cost-share coverage for deductibles (how much you pay before your insurance pays the rest), copayments and coinsurance. (You might also see Medicare Parts A and B referred to as Original Medicare.)
2. Specified Low-Income Medicare Beneficiary (SLMB). This helps with Medicare Part B premiums only.
3. Qualified Individual (QI). These programs help pay Medicare Part B premiums for members with higher incomes than those with SLMB.
4. Qualified Disabled and Working Individuals (QDWI). This is for people who are disabled and have returned to work, causing them to lose their premium-free Medicare Part A coverage. In this situation, QDWI can be used toward paying the premiums.

If you have partial dual eligibility, you can get some Medicaid services through the Medicare Savings Programs (MSPs). MSPs are managed by the Medicaid program in each state. MSPs cover certain Medicare costs, such as Medicare Parts A and B premiums and deductibles, copayments and coinsurance, explains Gross. But you don’t receive full Medicaid benefits.

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 — meaning your income or resources are slightly higher than the state limits — you should still apply.” That’s because some states only count certain types, or specific amounts, of income or resources, so you still might make the cut.

Need help navigating your Medicare plan? Explore your options now or contact a licensed insurance agent at 1-844-211-7730.

How do Medicare and Medicaid work together when you are enrolled in both?

For any service you receive, Medicare pays first and may cover all eligible costs. Then, any qualified costs not covered by Medicare may be covered by Medicaid. Some areas of care that may be covered by Medicaid when Medicare won’t cover them include:

• Nursing home care
• Personal care
• Prescription drug coverage

Depending on your state, Medicaid may cover other services such as dental, vision and hearing.

What is a Dual Eligible Special Needs Plan (D-SNP)?

A Dual Eligible Special Needs Plan, or D-SNP, is a special kind of Medicare Advantage plan that coordinates all covered Medicare and Medicaid managed care benefits under one health plan. You are eligible if you:

• Have Medicare Parts A and B (Original Medicare)
• Live in the dual plan’s service coverage area
• Qualify for Medicaid in your state

Need help finding a Medicare Advantage plan? Explore your options now, or contact a licensed insurance agent at 1-844-211-7730.

Sources:

Center for Health Care Strategies: “Beneficiaries Dually Eligible for Medicare & Medicaid.” February 2022. Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf

Hearing Loss Association of America: “Medicaid.” https://www.hearingloss.org/hearing-help/financial-assistance/medicaid/. Accessed June 22, 2023.

Kaiser Family Foundation: “A Profile of Medicaid-Medicare Enrollees (Dual Eligibles). January 2023. https://www.kff.org/medicare/issue-brief/a-profile-of-medicare-medicaid-enrollees-dual-eligibles/

Medicaid.gov. “Dental Care.” Retrieved from https://www.medicaid.gov/medicaid/benefits/dental-care/index.html Accessed October 13, 2023.

Medicaid.gov. “Medicaid Eligibility.” Retrieved from https://www.medicaid.gov/medicaid/eligibility/index.html Accessed October 13, 2023.

United Healthcare: “Full vs. partial dual eligibility — what’s the difference?” July 2022. https://www.uhccommunityplan.com/dual-eligible/eligibility/full-and-partial-dual-eligibility

U.S. Centers for Medicare and Medicaid Services: “Medicaid.” https://www.medicare.gov/basics/costs/help/medicaid Accessed July 10, 2023.

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