Medicare-Medicaid Dual Enrollment

When you turn 65, Medicare will become your main health insurance plan. However, most people are less familiar with another health care program, Medicaid, and what it means if you are eligible for both Medicare and Medicaid.

If you are dual eligible, Medicaid may pay for your Medicare out-of-pocket costs and certain medical services that aren’t covered by Medicare. Similar to Medicare, Medicaid is a health coverage program covered by the US government.

It was originally established to help low-income individuals access health care coverage. Unlike Medicare, however, Medicaid is partially funded by state governments. This means that states have the flexibility to design their Medicaid programs to best meet the needs of their residents as long as the program meets the minimum federal guidelines. As a result, Medicaid eligibility, services, and cost-sharing policies will vary state-by-state, while the Medicare program is consistent across all states.

Qualification for Medicaid and Medicare

Over 10 million individuals are currently enrolled in both Medicaid and Medicare. These individuals are known as “dual eligible beneficiaries” because you may qualify for both programs. As long as you meet the federal qualifications for Medicare eligibility and the state-specific qualifications for Medicaid eligibility, you will qualify as a dual eligible. To qualify for Medicare, individuals generally need to be 65 or older; or have a qualifying disability; or be diagnosed with End-Stage Renal Disease.

There are several levels of assistance an individual can receive as a dual eligible beneficiary. The term “full dual eligible” refers to individuals who are enrolled in Medicare and receive full Medicaid benefits. Individuals who receive assistance from Medicaid to pay for Medicare premiums or cost sharing are known as “partial dual eligible”.

Full Eligibility

Full dual eligible coverage: Qualifications for Medicaid vary by state, but, generally, people who qualify for full dual eligible coverage are recipients of Supplemental Security Income (SSI). The SSI program provides cash assistance to people who are aged, blind, and disabled to help them meet basic food and housing needs. The 2016 income eligibility limit for SSI is roughly $733 per month for an individual and $1,100 per month for a couple. Additional assets are limited to $2,000 for an individual and $3,000 for a couple. Qualifying assets typically include things like checking and savings accounts, stocks, real estate (other than your primary residence), and vehicles if you own more than one.

Partial Eligibility

Partial dual eligible coverage: Individuals who are partial dual eligible typically fall into one of the following four “Medicare Savings Program” (MSP) categories.

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