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.
Dual coverage sounds complicated, but you typically receive your benefits through each program. For Medicare benefits, Original Medicare or Medicare Advantage 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.
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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. [i]
For some dual eligible groups, Medicaid can cover some or all of the following:
- Medicare Part A premiums
- Medicare Part B premiums
- Co-insurance under Part A or Part B
- Full Medicaid Coverage
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.
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