Dual Enrollment Medicare And Medicaid


Who Is Eligible For Medicare

A Special Enrollment for Dual Medicare/Medicaid Recipients

Medicare is a federally-run health insurance program for people age 65 and over and people under the age of 65 who have a qualifying disability. Original Medicare, which is proved by the federal government, consists of Medicare Part A hospital insurance and Medicare Part B medical insurance.

To be eligible for Medicare, you must meet the following Medicare eligibility requirements:

  • You are at least 65 years old and are eligible for retirement benefits from Social Security or the Railroad Retirement Board, OR you are under 65 and are eligible for disability benefits from Social Security or the Railroad Retirement Board. You can also qualify if you have Lou Gehrigs disease or permanent kidney failure .
  • You are a U.S. citizen or a permanent legal resident who has lived in the U.S. for at least five years.
  • You may also be eligible for Medicare if you or your spouse is a current or former government employee who has paid Medicare taxes while working.

    If you do not qualify for retirement or disability benefits, you may still be eligible for Medicare at age 65, but you may have to pay a monthly premium for Medicare Part A.

    Some Seniors May Qualify For Other Medical

    In addition to Medicaid, many seniors may be eligible for other assistance, depending on the state they reside in. For example, many states offer a Home and Community Based Services waiver that provides support with all or part of the cost of assisted living or other long-term care. These waivers can help seniors who require support beyond the hospital stays, prescriptions and other services covered by Medicare.

    Seniors who are unsure about how Medicare works or who would like to know more about their coverage options can seek advice from their local State Health Insurance Assistance Program . SHIP is a free service that offers unbiased, reliable Medicare counseling and assistance to help people find the best coverage for their needs.

    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

    Partial Eligibility

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

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    Definition Of Dual Eligibility

    Individuals must be enlisted in Medicare Part A or Medicare Part B to be considered as dually eligible beneficiaries. People can choose Medicare Part C, also known as Medicare Advantage, as an alternative to Original Medicare Part A and B coverages. Moreover, participants in the Medicare Advantage program receive Medicare Part A, Part B, and, in some cases, Part D, which provides prescription drug coverage.

    Furthermore, individuals must be enrolled in either a full-service Medicaid program or one of dual eligibility Medicaids Medicare Savings Programs . Medicaid full coverage includes hospital services , physician visits, laboratory facilities, and x-rays. Medicaid also covers nursing home care and, in many cases, limited personal care services in ones home. While some states provide long-term care and community supports through their state Medicaid program, many states offer these aids through 1915 Medicaid waivers.

    Benefits Of Having Both

    A Primer on Medicare  What is the role of Medicare for ...

    Dual plans offer extra benefits at no extra cost.

    Dual plans go beyond either Medicaid or Original Medicare alone. Youll still keep the Medicaid benefits you get today. And better yet, with a dual plan, you could get many extra benefits and features than Original Medicare at no extra cost. These extra benefits may include:

    • Dental care, plus credit for restorative work.
    • Eye exams, plus credit for eyewear.
    • Hearing exams, plus credit for hearing devices.
    • Rides to health care visits and the pharmacy.

    As an added bonus, people who are dual eligible can usually enroll for no monthly premium.

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    How Are My Health Care Costs Reimbursed If I Have Medicare And Medicaid

    When dual eligible beneficiaries have healthcare expenses, Medicare pays first and Medicaid pays last. But this is not the case for things Medicare doesnt cover, like long-term care. If Medicaid is covering a beneficiarys long-term care, Medicare will still be the primary payer for any Medicare-covered services like skilled nursing care or physical therapy.

    Although it is less common, if a dual eligible individual has additional coverage then Medicare pays first, Medigap will pay second, and Medicaid is the last payer for their claims .

    What Is The Income Range For Beneficiaries Who Are Dual Eligibles

    Generally, beneficiaries earning less than 135 percent of the federal poverty level are eligible for the MSP if they also have limited savings . This equates to $17,226 annually for single beneficiaries and $23,274 for married couples. Beneficiaries qualify for full Medicaid benefits if their incomes and assets are even lower .

    Many seniors who live in nursing homes are dual eligible: they qualify for Medicare based on their age, and Medicaid because of their financial circumstances. It is also common for Medicare beneficiaries who are under 65 and live on Social Security Disability Insurance to receive Medicaid benefits.

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    What Is Dual Eligibility

    Dual eligibility is the term used to explain that you qualify for both Medicare and Medicaid benefits.

    This usually occurs in situations where you already qualify for Medicare but because of low income, cannot afford the remaining costs such as deductibles or your portion of the medical bills. If you are dually eligible for both programs, most of your health care expenses will likely be covered, leaving you with a smaller bill to foot for the care you need.

    About 9 million people in the United States have dual eligibility for Medicare and Medicaid.

    Four Sets Of Resources For Understanding And Addressing The Needs Of Dual Enrollees

    Medicaid & Medicare: Dual Eligibility Plans (DSNP)

    Urban Institute staff contribute to a wide variety of research to help policymakers and administrators understand dual enrollees. This body of research spans descriptive studies, quantitative evaluation work, technical data issues, and policy analyses aimed at improving the financing and delivery of care for dual enrollees. Here you will find our resources divided into four sections:

    Descriptive Features of Dual Enrollees and Eligible Nonenrollees

    Dual enrollees generate significant interest for many reasons however, they are not a homogenous group. Descriptive analyses on dual enrollees, as well as dually eligible nonenrollees, shed light on the many distinctive and cross-cutting features of this population.

    Integrated Care for Dual Enrollees


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    Unitedhealthcare Connected For Mycare Ohio

    UnitedHealthcare Connected® for MyCare Ohio is a health plan that contracts with both Medicare and Ohio Medicaid to provide benefits of both programs to enrollees. If you have any problem reading or understanding this or any other UnitedHealthcare Connected® for MyCare Ohio information, please contact our Member Services at from 7 a.m. to 8 p.m. Monday through Friday for help at no cost to you.

    Si tiene problemas para leer o comprender esta o cualquier otra documentación de UnitedHealthcare Connected® de MyCare Ohio , comuníquese con nuestro Departamento de Servicio al Cliente para obtener información adicional sin costo para usted al de lunes a viernes de 7 a.m. a 8 p.m. .

    Medicare And Medicaid Coverage For Dual

    Medicare is the primary payer for most services, but Medicaid covers benefits not offered by Medicare. Medicare coverage for dual-eligibles includes hospitalizations, physician services, prescription drugs, skilled nursing facility care, home health visits, and hospice care. Under Medicaid, states are required to cover certain items and services for dual-eligibles, including long-term nursing facility services and home health services. Although states are required to cover certain populations and services, they have the option to expand coverage beyond these mandatory levels , and accordingly state Medicaid programs vary in scope. Dual-eligibles may be categorized as full-benefit or partial-benefit. Those with full benefits may receive the entire range of Medicaid benefits those with partial-benefits do not receive Medicaid-covered services, but Medicaid covers their Medicare premiums or cost-sharing, or both. Partial benefit dual-eligible beneficiaries have limited income and assets, but their income and assets are not low enough to qualify them for full Medicaid benefits in their state.

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    Medicare Vs Medicaid 101

    An animated white speech bubble appears over an animated character’s yellow and blue head.

    ON SCREEN TEXT: Medicaid 101

    The speech bubble and character fall away. Blue text appears on a light blue background. White text appears in two animated circles below. The blue and green circles overlap.

    ON SCREEN TEXT: Medicaid is a joint federal and state health program. Federal State

    The text and circles fall away. Blue text appears surrounded by blue animated disks with dollar signs on them. Animated individual and family character graphics appear below the text.

    ON SCREEN TEXT: It is for individuals, families and children with limited income & resources.

    The text and graphics fall away. A white map of the continental U.S. appears on a light blue background. Green map marker icons dot the map. Blue text appears in the center of the map.

    ON SCREEN TEXT: Each state creates its own Medicaid programs based on federal guidelines.

    The map disappears. Blue text appears surrounded by animated green and white form and plus sign graphics.

    ON SCREEN TEXT: Medicaid programs have mandatory benefits & optional benefits.

    The text and graphics fall away. Blue text appears over an animated dark blue scale graphic. Yellow animated coins pile up on the left side of the scale and animated books pile up on the right side.

    ON SCREEN TEXT: Medicaid costs will vary based on a person’s income and the state’s Medicaid rules.

    ON SCREEN TEXT: Eligibility varies based on a state’s Medicaid rules.

    Efforts To Integrate Medicare And Medicaid Benefits

    Enrollment and Spending in Medicaid

    Dual-eligibles typically receive their Medicare and Medicaid benefits through each program separately. For Medicare benefits, beneficiaries may opt to enroll in Medicare’s traditional fee-for-service program or in a private Medicare Advantage plan , which is administered by a Managed Care Organization , under contract with the Centers for Medicare & Medicaid Services , the agency in the Department of Health and Human Services that administers the Medicare program and oversees state Medicaid programs. In addition, dual-eligibles may choose a type of MA plan called a dual-eligible special needs plan , which is designed to target the needs of this population. For Medicaid benefits, beneficiaries generally enroll in their state’s Medicaid FFS program or a Medicaid managed care plan administered by an MCO under contract with the state.

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    General Fund Revenue As A Share Of Total Medicare Spending

    This measure, established under the Medicare Modernization Act , examines Medicare spending in the context of the federal budget. Each year, MMA requires the Medicare trustees to make a determination about whether general fund revenue is projected to exceed 45 percent of total program spending within a seven-year period. If the Medicare trustees make this determination in two consecutive years, a “funding warning” is issued. In response, the president must submit cost-saving legislation to Congress, which must consider this legislation on an expedited basis. This threshold was reached and a warning issued every year between 2006 and 2013 but it has not been reached since that time and is not expected to be reached in the 20162022 “window”. This is a reflection of the reduced spending growth mandated by the ACA according to the Trustees.

    What Are The State

    Benefits for dual eligible beneficiaries candiffer based on your state of residence. Differences by state may include:

    • Medicaid offered through Medicaid managed care plans
    • fee-for-service Medicaid coverage
    • plans that include all Medicare and Medicaid benefits

    Income and resource standards are defined by federal law for full Medicaid and the Medicare Savings Programs. At their discretion, states can effectively raise the federally mandated limits.

    Youre also considered a dual eligible beneficiary if youre enrolled in Medicare Part A or Part B and receiving cost-sharing through a Medicare savings program .

    Below is table summarizing the benefits and eligibility criteria for each of the different MSPs in 2021:

    Specified Low-Income Medicare Beneficiary program assists in the payment of Part B premiums individual monthly income of $1,308 or less, individual resources limit of $7,970 married couple monthly income of $1,762 or less, married couple resources limit of $11,960

    In addition to the Medicare savings programs, you also may be eligible for some of the following needs-based programs through Medicare:

    • PACE : a Medicare-Medicaid joint program that provides medical and social services for people with significant needs who want to continue living at home
    • Medicares Extra Help program: can help those with low incomes get the prescription drugs they need at reduced or no cost

    Dual eligibility for Medicare and Medicaid means that youre enrolled in Medicare and either:

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    How Do You Qualify For Dual Eligibility

    To be dual eligible means to be eligible for Medicare Part A and/or Part B along with full Medicaid benefits and/or assistance. Being dual eligible and enrolling in Medicare and Medicaid means you typically get assistance with Medicare costs such as premiums, coinsurance and deductibles through a Medicare Savings Program .

    Understanding The Difference Between Medicare And Medicaid

    Medicare Dual Special Needs Plans (DSNP’s)

    It is possible to use both Medicare and Medicaid to help with the cost of medical procedures and exams, but you should know how the two programs are different.

    Medicare offers health insurance benefits to people who are at least 65-years-old or for people who have disabilities or kidney failure. This kind of insurance is provided by the U.S. federal government and consists of multiple parts that cover different medical needs, such as hospital insurance, medical insurance and prescription medications.

    Medicare also offers another option Medicare Advantage Plan that allows people to receive their Medicare benefits through a private insurance company. This avenue allows beneficiaries to customize their health insurance needs.

    Medicaid is a state program that helps low-income individuals and families with the costs of healthcare. This is different from Medicare because you do not have to have a disability or be over the age of 65 to receive health insurance benefits.

    Medicaids goal is to help people who truly cannot afford the cost of health services because of their income level regardless of age. People who qualify for Medicaid may get assistance paying for premiums, deductibles, coinsurance, copayments, and prescription drugs. And in some cases, Medicaid covers things that Medicare will not, such as the cost of nursing home stays or personal care attendants.

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    Definitions Of Dual Eligibility

    Important factors that State and Federal policymakers face when designing care systems for dually eligible beneficiaries are the statutory definitions of dual eligibility. State Medicaid agencies are required to assist certain low-income Medicare beneficiaries with payment of Medicare premium and cost-sharing provisions. As described by , the Medicare buy-in provision has expanded and evolved over time through a series of incremental expansions. For example, a Medicare beneficiary enrolled in Part A and/or Part B, who also receives State support in meeting any Medicare cost-sharing requirements may be considered a dually eligible beneficiary.

    American Disabilities Act Notice

    In accordance with the requirements of the federal Americans with Disabilities Act of 1990 and Section 504 of the Rehabilitation Act of 1973 , UnitedHealthcare Insurance Company provides full and equal access to covered services and does not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

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    C: Medicare Advantage Plans

    With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were formally given the option to receive their Original Medicare benefits through capitated health insurance Part C health plans, instead of through the Original fee for service Medicare payment system. Many had previously had that option via a series of demonstration projects that dated back to the early 1970s. These Part C plans were initially known in 1997 as “Medicare+Choice”. As of the Medicare Modernization Act of 2003, most “Medicare+Choice” plans were re-branded as “Medicare Advantage” plans . Other plan types, such as 1876 Cost plans, are also available in limited areas of the country. Cost plans are not Medicare Advantage plans and are not capitated. Instead, beneficiaries keep their Original Medicare benefits while their sponsor administers their Part A and Part B benefits. The sponsor of a Part C plan could be an integrated health delivery system or spin-out, a union, a religious organization, an insurance company or other type of organization.

    The intention of both the 1997 and 2003 law was that the differences between fee for service and capitated fee beneficiaries would reach parity over time and that has mostly been achieved, given that it can never literally be achieved without a major reform of Medicare because the Part C capitated fee in one year is based on the fee for service spending the previous year.


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