Medicare and Medicaid are different government-funded healthcare programs. To be eligible for both, a person will need to qualify for either partial-dual or full-dual coverage.
Both Medicare and Medicaid are in place to help people pay for healthcare costs. If a person qualifies for both, the government refers to them as dually eligible.
Around 12 million people in the United States are dually eligible for Medicare and Medicaid, according to Medicaid.gov.
This article explains dual eligibility for Medicare and Medicaid, including who is eligible and what to know about each program.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
To be eligible to receive both Medicare and Medicaid, a person must qualify for either partial-dual or full-dual coverage.
Eligibility for partial-dual coverage depends on the support that a person receives from Medicaid. Examples of the varied coverage may include:
- Part A premium (if applicable)
- Part B premium
- coinsurances
- copayments
- deductibles
Those who qualify for full coverage under Medicare and Medicaid may receive all the benefits for which partial-dual enrollees qualify, plus additional benefits, such as long-term care services.
Medicaid provides various programs based on a person’s income compared to the Federal Poverty Level (FPL). Examples include programs that help pay for prescription drugs.
Dual-eligible beneficiaries are people who have both Medicare and Medicaid. Each state is responsible for determining Medicaid coverage, and, as such, Medicaid benefits may vary.
Receiving both Medicare and Medicaid can help decrease healthcare costs for those who are often most in need of treatment.
As a general rule, Medicare will usually first pay for health services, and Medicaid will then cover any differences up to its payment limits.
According to a 2020 data analysis brief, 37.9% of dual-eligible beneficiaries met Medicare requirements based on a disability in 2019.
Anyone 65 years of age or older can qualify for Medicare.
A person can receive premium-free Part A (hospital coverage) benefits if they or their spouse is 65 or older and has paid sufficient Medicare taxes through previous employment.
They can also qualify for Medicare Part B, which is outpatient medical coverage for doctor visits and many other medical-related expenses.
Some people younger than 65 can be eligible for Medicare, including those with:
Some people, such as those with disabilities, may have a waiting period of 24 months before they can qualify for Medicare.
People who are dual-eligible may have chronic conditions and functional limitations that require more medical care.
On average, Medicare spends
Eligibility for Medicaid depends on the region where a person lives, as some states have different criteria for qualification.
However, some groups, such as people receiving Supplemental Security Income (SSI), qualified pregnant people, or families with a low income, are automatically eligible according to federal law.
Medicaid standards can change every year. If a person was unsuccessful in a prior application, they might qualify at a later date.
One of the most important factors for Medicaid eligibility is where a person falls on the FPL. The FPL, which the Department of Health and Human Services (HHS) sets every year, establishes a person’s eligibility for specific programs.
There is an FPL for the 48 contiguous states and the District of Columbia, with a higher FPL in Alaska and Hawaii. The FPL varies according to a family’s size.
There are a few key differences between Medicare and Medicaid.
Medicaid
Medicaid is a health insurance program that provides financial assistance to individuals and families with a low income or limited financial resources.
The federal government sets rules and regulations regarding Medicaid, and individual states are responsible for operating Medicaid programs.
People of all ages can apply for Medicaid. Medicaid programs may cover the following:
- children
- families
- pregnant people
- people with disabilities
- older adults
Medicare
Medicare is an insurance plan for people at or over the age of 65 and for others with qualifying medical conditions.
A person must meet eligibility criteria based on their work history or that of their spouse. They can qualify for premium-free hospital coverage and pay a premium for outpatient medical and prescription drug coverage.
A person does not have to meet any income-related criteria to qualify for Medicare.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicaid benefits and coverage can vary widely among states. Some states may expand their Medicaid coverage beyond traditional income limits.
The Medicaid website can help people find services available to them based on their geographical location.
Medicaid is not the only government-sponsored resource that helps pay for medical costs. An individual can also apply for Extra Help, a program that helps beneficiaries with Medicare Part D, which covers outpatient prescription drug costs.
To qualify for Extra Help, a person’s combined investments, real estate, and savings must not exceed $17,220 if a person is single or $34,360 if they are married and living with their spouse.
A person can visit the Social Security Administration website to learn more about getting and applying for Extra Help.
A person may qualify for both Medicare and Medicaid based on their health and income level.
If a person is dual-eligible, Medicare will usually pay for health expenses first, and Medicaid may help pay for out-of-pocket and noncovered expenses.
Medicaid coverage varies depending on each state’s rules and income level requirements.