Who Is Eligible for Both Medicare and Medicaid? A Guide to Dual Eligibility

Medicare and Medicaid are two cornerstone programs in the U.S. healthcare system, but they serve different purposes. Medicare is a federal program primarily for seniors and certain younger individuals with disabilities, while Medicaid is a state-administered program designed to help those with limited income and resources.

Some individuals qualify for both. These people are known as dual eligible, and understanding this status can be life-changing, especially for those facing chronic health conditions or financial challenges, as dual eligibility offers more comprehensive healthcare coverage and helps reduce out-of-pocket expenses.

At Unified Health, we specialize in helping individuals determine their eligibility, understand their benefits, and choose the right plan for their individual needs. Whether you’re just beginning your journey or exploring additional options, this guide is designed to help you make informed decisions.

What Does it Mean to be Dual Eligible?

If you qualify for both Medicare and Medicaid, you are considered dual eligible. That means you receive benefits from both programs, which can significantly reduce the cost of your healthcare.

Medicare typically covers services like hospital visits, outpatient care, and prescription drugs, while Medicaid can provide additional support, such as long-term care, dental, and vision services (depending on your state).

Being dual eligible helps fill the gaps left by either program alone. It’s a critical safety net for individuals who are aging, have disabilities, or live with chronic conditions, and need consistent, affordable access to care.

Basic Eligibility Criteria for Medicare

To qualify for Medicare, you must meet at least one of the following conditions:

• Be 65 or older

• Be under 65 with a qualifying disability

• Have End-Stage Renal Disease (ESRD)

You must also be a U.S. citizen or a legal permanent resident who has lived in the country for at least five years. Enrollment typically happens through the Social Security Administration.

Basic Eligibility Criteria for Medicaid

Medicaid eligibility is largely based on income and resources and varies by state. Generally, it supports:

• Low-income individuals and families

• Seniors with limited income

• People with disabilities

• Pregnant women and children

Because Medicaid is state-run, the income thresholds and application processes can differ widely. However, the federal government provides baseline requirements that all states must follow.

Who Is Eligible for Both Medicare and Medicaid?

So, who is eligible for both Medicare and Medicaid? Dual eligibility is based on a combination of age, health status, income, and assets. You may qualify if:

• You are 65 or older with limited income and financial resources

• You are under 65 with a qualifying disability and meet state Medicaid income guidelines

• You have specific medical conditions like End-Stage Renal Disease (ESRD) and meet Medicaid financial requirements

• Your income and assets fall within your state’s limits for Medicaid, even if you already receive Medicare

Keep in mind, eligibility is not automatic. You must apply for Medicare and Medicaid separately through their respective channels.

Types of Dual Eligibility

Not all dual eligibles receive the same level of benefits. There are two main categories:

Full Dual Eligible

• Receives full Medicaid benefits

• Medicaid pays for Medicare premiums, deductibles, copayments, and coinsuranceMay also receive additional services not covered by Medicare

Partial Dual Eligible

• Medicaid helps only with Medicare premiums (not full cost-sharing)

• May qualify for programs such as:

  • QMB (Qualified Medicare Beneficiary)

  • SLMB (Specified Low-Income Medicare Beneficiary)

  • QI (Qualified Individual)

The level of assistance depends on your income and assets, but even partial help can make a big difference.

What Benefits Are Available to Dual Eligible Individuals?

Being dual eligible means you may receive a combination of services covered by both Medicare and Medicaid. Benefits may include:

• Hospital and outpatient care

• Prescription drug coverage (Medicare Part D)

• Long-term services and supports (via Medicaid)

• Dental and vision care (varies by state)

• Non-emergency medical transportation

How to Apply for Medicare and Medicaid

To apply for Medicare or Medicaid, each program has its own enrollment process:

• Medicare: Apply through the Social Security Administration at SSA.gov

• Medicaid: Apply through your state Medicaid office or HealthCare.gov

Navigating two separate applications can be confusing. Unified Health helps simplify the process and ensures you meet all the deadlines and documentation requirements.

How Unified Health Supports Dual-Eligible Individuals

At Unified Health, we specialize in helping people who qualify for both Medicare and Medicaid find the right plan. Our services include:

• Free consultations to evaluate your eligibility

• Personalized plan comparisons, including Dual Eligible Special Needs Plans (D-SNPs)

• Ongoing support to ensure you're maximizing your coverage

Our goal is to minimize confusion and make your healthcare as seamless and cost-effective as possible.

FAQs About Dual Eligibility

Can I get both Medicare and Medicaid if I’m still working?

Yes, but your income may affect your Medicaid eligibility. Some working individuals still qualify if their earnings are below state thresholds.

What happens if my income changes?

If your income increases, you may lose some Medicaid benefits, but you’ll likely still be covered by Medicare. It’s important to report any changes promptly.

Will I need to pay for anything out-of-pocket?

Dual eligible individuals often pay little to nothing out-of-pocket, especially if they’re full dual eligible. Medicaid covers many of the costs Medicare doesn’t.

Can I switch plans if I’m dual eligible?

Yes. You have a Special Enrollment Period (SEP) that allows you to switch plans once per quarter for the first three quarters of the year.

Why Dual Eligibility Matters and How to Get Started

Dual eligibility offers a powerful combination of benefits that can significantly improve your health coverage and reduce your financial burden. If you think you may qualify or just want to explore your options, Unified Health is here to help.

Contact us today to get started with a free consultation and let our team walk you through every step of the process.

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