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How Does My Coverage Change If I’m Dual Eligible?

What you can expect when Medicaid and Medicare coverage work together

Reviewed by: Michael Howard, Licensed Insurance Agent. Written by: Andrew Hall.

Older couple amused by mild explosives.

Key Takeaways

  • Dual-eligible beneficiaries are individuals who receive both Medicare and Medicaid benefits.

  • The two programs cover many of the same services, but Medicare pays first for the Medicare-covered services that are also covered by Medicaid.

  • Medicaid covers services that Medicare does not cover.

How Does Dual Medicare and Medicaid Coverage Work?

Dual coverage sounds complicated, but you typically receive your benefits through each program. For Medicare benefits, Original MedicareOriginal Medicare (Parts A and B) is fee-for-service health insurance available to all Americans aged 65 and older and some individuals with disabilities. Original Medicare is provided by the federal government and is made up of two parts: Part A (hospital insurance) and Part B (medical insurance). or Medicare AdvantageMedicare Advantage is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). administered by the Centers for Medicare and Medicaid Services (CMS) or a Managed Care provider have oversight with Medicaid. For Medicaid benefits, a dual enrollee will enroll in their state’s Medicaid program. Medicare is the primary payer for most services, but Medicaid covers benefits not offered by Medicare.

What’s Covered?

Your Medicare coverage does not vary with dual enrollment, but Medicaid categories and programs vary based on income, and may impose restrictions. There are  several Medicare Savings Programs, including:

  • Qualified Medicare Beneficiary (QMB) program: supports the payment of Medicare Part A and Part B premiums.
  • Specified Low-Income Medicare Beneficiary (SLMB) program: supports the payment of Part B premiums for individuals with an income greater than 100 percent but less than 120 percent of the Federal Poverty Level
  • Pharmacy: Medicare Part D covers premiums deductibles, and other prescription drugs for all Dual-eligible beneficiaries. [1]

For some dual eligible groups, Medicaid can cover some or all of the following:

  • Medicare Part A premiums
  • Medicare Part B premiums
  • Co-insuranceCoinsurance is the percentage of your medical costs that you pay after you meet your deductible. The remaining amount is paid by your insurance company. For example: If you have a $1,000 medical bill and your coinsurance is 20%, you'll pay $200. Your insurance company will cover the final $800. under Part A or Part B
  • Full Medicaid Coverage

Can I Change Plans?

When you become eligible for Medicare and Medicaid, you have a special enrollment period. The enrollment period begins with your eligibility and ends two months after losing Medicaid. Your coverage begins on the first day of the following month.

Dual-eligible beneficiaries can change plans once every calendar quarter for the first three quarters. The effective date of any change is always the first day of the next month.

January 1 – March 31

April 1 – June 30

July 1 – September 30

Fourth-quarter changes must be made during the Annual Enrollment Period (AEP), which runs between October 15 and December 15, and the change will take effect on January 1.

FAQs

If I have Medicare, how do I know if I’m eligible for Medicaid?

Since Medicaid is administered by the Medicaid agency in your state, eligibility may vary from one state to another. There is not a nationwide standard, but contacting your state’s Medicaid office or a GoHealth licensed insurance agent is the best way to find out if you qualify.

If I want to discuss my coverage, do I have to contact both Medicare and Medicaid, or do they work together for those with both?

Medicare and Medicaid do not work together directly. You can always contact your regional Medicare office. [2] Regional Medicare offices work closely with state Medicaid agencies.

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