Can You Have Medicare and Medicaid? What Dual Eligibility Means for You

If you qualify for both Medicare and Medicaid, you may be eligible for a powerful form of healthcare coverage called dual eligibility. This setup is designed to offer broader benefits and greater financial protection for people who meet the criteria for both programs.

Medicare, a federally funded program, primarily supports individuals aged 65 and older, or those under 65 with certain qualifying disabilities or medical conditions. Medicaid, on the other hand, is a state-managed program focused on assisting low-income individuals and families with healthcare costs. Together, these two programs can provide a safety net that covers most, if not all, of your essential medical needs.

In this guide, we’ll explain how dual eligibility works, who qualifies, the kinds of coverage you can expect, and how you can apply with help from Unified Health along the way.

Who Qualifies for Both Medicare and Medicaid?

To become dual eligible, you must independently qualify for each program.

Medicare eligibility includes:

• Age 65 or older

• Under 65 with a qualifying disability (after 24 months on SSDI)

• Diagnosis of ALS or End-Stage Renal Disease (ESRD)

Medicaid eligibility depends on:

• Income and asset limits (varies by state)

• Household size and specific needs

• In some states, receiving SSI automatically qualifies you

The key is meeting both sets of requirements. If you do, you could access expanded healthcare benefits with little to no out-of-pocket costs.

What Is Dual Eligibility and How Does It Work?

Dual eligibility simply means you’re enrolled in both Medicare and Medicaid. These two programs coordinate to maximize your healthcare coverage and reduce your out-of-pocket expenses.

In most cases, Medicare acts as your primary insurance. It pays first for services it covers, such as doctor visits, hospital stays, and outpatient care. Medicaid then acts as a secondary payer, helping to cover costs that Medicare does not, like deductibles, copayments, or services that fall outside of Medicare’s coverage.

This coordination can dramatically reduce the amount you spend on healthcare each year. For individuals with full dual eligibility, it’s not uncommon to have almost all medical expenses covered, including prescription drugs, long-term care, and more.

Types of Dual Eligibility and Program Levels

Not all dual-eligible individuals receive the same level of benefits. Depending on your income and resources, you may qualify for either full or partial assistance.

Full dual-eligible individuals get the most comprehensive coverage. In addition to their Medicare benefits, Medicaid helps pay for virtually all healthcare costs, including premiums, deductibles, and services not covered by Medicare.

Partial duals may not qualify for full Medicaid benefits, but they can still receive help through Medicare Savings Programs. These include the Qualified Medicare Beneficiary (QMB) program, which covers Medicare premiums and cost-sharing expenses, and programs like SLMB (Specified Low-Income Medicare Beneficiary) and QI (Qualifying Individual), which help cover Medicare Part B premiums. Your state determines which program you qualify for, and the level of financial help increases as your income and assets decrease.

What Does Medicare Cover for Dual-Eligible Individuals?

Even if you're dual eligible, Medicare still serves as your primary health insurance. It’s responsible for most of your medical coverage.

Medicare Part A typically covers hospital stays, skilled nursing facility care, and some home health services. Part B includes outpatient care, doctor visits, lab work, and durable medical equipment. Many dual eligibles also enroll in Part D, which provides prescription drug coverage through a private plan approved by Medicare.

For those who qualify, Medicaid steps in to cover many of the costs that Medicare does not. This includes things like coinsurance, deductibles, and premiums, depending on your eligibility level. The result is that many dual-eligible individuals experience significantly reduced out-of-pocket expenses for healthcare.

What Extra Services Can Medicaid Provide?

Medicaid covers a range of services that Medicare typically does not. These added benefits can vary by state and level of eligibility, but they often make a big difference in quality of life.

Possible Medicaid-covered services include:

• Long-term care and custodial support

• Dental care (cleanings, fillings, dentures)

• Vision services (eye exams, glasses)

• Hearing services (including hearing aids)

• Non-emergency medical transportation (to doctor visits or pharmacies)

• Home- and community-based services (HCBS) for those who need support at home

These services are especially helpful for seniors or individuals with chronic health conditions who need extra support to live independently.

What Are My Plan Options If I’m Dual Eligible?

Once you become dual eligible, you have a few options for how your benefits are administered.

The first option is to keep your Medicare and Medicaid benefits separate. While this approach gives you flexibility in choosing providers, it often requires navigating two systems, dealing with separate billing, and managing more paperwork.

A second option is to enroll in a Dual Eligible Special Needs Plan (D-SNP). These are Medicare Advantage plans specifically designed for individuals with both Medicare and Medicaid. D-SNPs combine Medicare and Medicaid benefits into a single, coordinated plan. They often include additional features, like prescription drug coverage, dental or vision benefits, and access to a care coordinator who helps manage your care across providers.

Finally, if you qualify and need long-term care, you might be eligible for the Program of All-Inclusive Care for the Elderly (PACE). This option offers a team-based, holistic approach to managing healthcare, especially for those who want to remain in their home instead of entering a nursing facility.

Each of these options has its pros and cons, and choosing the right one depends on your health needs, preferences, and the availability of plans in your area.

How Do You Apply for Dual Coverage?

Enrolling in Medicare and Medicaid requires two separate applications.

Medicare Enrollment:

• Apply through the Social Security Administration

  • Online: ssa.gov

  • By phone or in person

Medicaid Enrollment:

• Apply through your state Medicaid office

• Requirements and procedures vary by state

• You’ll likely need:

  • Proof of income and assets

  • Identification documents

  • Medical records (if applying due to disability)

If the process feels overwhelming, Unified Health is here to help. Our licensed agents can:

• Confirm your eligibility

• Help gather the right documents

• Identify the best plan based on your needs

• Submit your applications and follow up to avoid delays

What If Your Eligibility or Needs Change?

Your healthcare needs and financial circumstances may change over time. It’s important to know that your coverage options can shift as well.

If your income increases or you gain new assets, you may lose eligibility for Medicaid or shift from full to partial dual status. Moving to a new state can also affect your Medicaid benefits, since each state runs its program differently. Gaining or losing other types of coverage, such as employer-sponsored insurance, may also affect your eligibility or plan options.

That’s why regular plan reviews, especially during annual enrollment periods, are crucial. Unified Health can help assess whether your current plan still meets your needs and guide you through any necessary changes.

Common Misconceptions About Having Both Medicare and Medicaid

There are a lot of myths about dual eligibility that may prevent people from getting the benefits they deserve.

One common misconception is that you can’t have both Medicare and Medicaid at the same time. In reality, many people qualify for and benefit from both programs. Another misunderstanding is that Medicaid replaces Medicare, but that’s not true. Medicare always pays first, and Medicaid covers what Medicare does not.

Some believe that everyone with dual eligibility receives the same benefits. That’s also incorrect. Medicaid coverage varies by state, and the level of assistance you receive depends on whether you qualify for full or partial benefits. Others think you’re stuck with the first plan you choose. Fortunately, dual-eligible individuals often have greater flexibility when it comes to switching plans, especially when enrolled in a D-SNP.

Understanding your rights is the first step to making informed decisions about your healthcare.

Recap and Next Steps

Being dual eligible for Medicare and Medicaid can provide you with comprehensive healthcare coverage, reduced out-of-pocket costs, and access to services that improve your overall quality of life.

To recap:

• You can have both Medicare and Medicaid.

• These programs work together to maximize your healthcare coverage.

• Your options include standalone coverage, D-SNPs, or PACE.

• Unified Health is here to help you understand your eligibility and select the best plan for your needs.

Contact Unified Health today to speak with a licensed agent who can walk you through the process and make sure you’re not leaving any benefits on the table.

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