Medicare and Medicaid are two government programs designed to provide healthcare coverage, but they serve different groups and have distinct eligibility criteria, coverage options, and costs. Here’s a quick breakdown:
- Medicare: A federal program for people aged 65+ or younger individuals with specific disabilities. It includes hospital stays (Part A), outpatient care (Part B), private insurance plans (Part C), and prescription drug coverage (Part D). Costs include premiums, deductibles, and coinsurance.
- Medicaid: A joint federal and state program for low-income individuals of any age. It covers a broader range of services, including long-term care, dental, and vision, often with little to no out-of-pocket costs.
Some individuals qualify for dual eligibility, meaning they can benefit from both programs. This reduces healthcare expenses significantly, as Medicaid can cover Medicare premiums, deductibles, and additional services.
Quick Comparison
| Criteria | Medicare | Medicaid |
|---|---|---|
| Eligibility | Age 65+ or certain disabilities | Income-based (varies by state) |
| Funding | Federal | Federal and State |
| Services Covered | Hospital, outpatient, prescription drugs | Broader, includes long-term care |
| Costs | Premiums, deductibles, coinsurance | Usually low or no cost |
| Dual Eligibility | Available, Medicaid reduces costs | Available, adds extra services |
Dual-eligible individuals can also enroll in Dual Eligible Special Needs Plans (D-SNPs), which combine benefits from both programs for simplified and coordinated care. To apply for both programs, individuals must meet separate eligibility requirements and apply through the respective agencies. Early planning and utilizing resources, like state Medicaid offices or caregiver support programs, can help streamline the process.
Medicaid + Medicare: How to Navigate Dual Special Needs Plans
Medicare vs. Medicaid: Main Differences
While both Medicare and Medicaid offer healthcare coverage, they serve distinct groups of people and operate under different funding structures. Knowing these differences can help families make better decisions about their healthcare options.
Who Qualifies for Each Program
The criteria for Medicare and Medicaid eligibility are quite different. Medicare eligibility is based on age or disability, not income. Most people qualify for Medicare when they turn 65, but younger individuals with specific disabilities or conditions, like End-Stage Renal Disease, can also qualify.
Your work history influences what you pay for Medicare Part A. For example, in 2025, if you’ve worked fewer than 30 quarters, you’ll pay a monthly premium of $518. Those with 30-39 quarters of work history will pay $285 per month.
Medicaid eligibility, on the other hand, is income-based and depends on household size, with income thresholds varying by state. Generally, U.S. citizens and legal residents earning 150% or less of the federal poverty level qualify in states that participate. Medicaid also covers certain groups, such as pregnant women, children, and people receiving Supplemental Security Income (SSI).
“Medicare provides medical coverage for many people age 65 and older and those with a disability. Medicare does not limit enrollment based on income level. Medicaid is designed for people of any age with limited income and is often a program of last resort for those without access to other resources.” – U.S. Department of Health and Human Services
When someone on Medicaid turns 65, they may qualify for both Medicare and Medicaid, creating what’s known as dual eligibility. This allows them to benefit from both programs’ coverage and cost-sharing features.
What Each Program Covers
The type of healthcare services each program covers also sets them apart. Medicare specializes in hospital and medical services, divided into four parts:
- Part A: Covers hospital stays and skilled nursing facilities.
- Part B: Focuses on outpatient care and doctor visits.
- Part C: Offers Medicare Advantage plans as alternatives to Original Medicare.
- Part D: Provides prescription drug coverage.
In contrast, Medicaid provides a broader range of services, including many that Medicare doesn’t cover. While benefits vary by state, Medicaid typically covers mandatory services like inpatient and outpatient hospital care, physician services, nursing facilities, and home health services. Importantly, Medicaid is the primary payer for long-term care, which Medicare and private insurance usually don’t cover.
Depending on the state, Medicaid may also include extra benefits like dental care, vision care, and personal assistance services. These additional services can help individuals remain in their homes instead of moving to institutional care.
Costs for Beneficiaries
The cost structures of Medicare and Medicaid are another key difference. Medicare involves various out-of-pocket costs, including premiums, deductibles, and coinsurance. Here’s a breakdown of some Medicare costs for 2025:
| Medicare Cost Component | 2025 Amount |
|---|---|
| Part B monthly premium | $185 |
| Part B annual deductible | $257 |
| Part A hospital deductible (per benefit period) | $1,676 |
| Part A coinsurance (days 61-90) | $419/day |
| Part A lifetime reserve days | $838/day |
| Part B coinsurance | 20% after deductible |
After meeting the Part B deductible, beneficiaries typically pay 20% of the cost for covered services, with no cap on annual out-of-pocket expenses under Original Medicare.
Medicaid, however, often eliminates out-of-pocket costs. Most Medicaid recipients pay nothing for covered services. For those who qualify for both programs, Medicaid can significantly reduce healthcare expenses by covering Medicare premiums, deductibles, and coinsurance.
For instance, Medicaid may pay the Medicare Part B premium, saving dual-eligible individuals the $185 monthly cost. This coordination between the two programs can make healthcare much more affordable for those who qualify for both.
What is Dual Eligibility?
Dual eligibility refers to individuals who qualify for both Medicare and Medicaid at the same time. This unique status provides access to additional benefits and reduces healthcare costs, making it a critical option for many older adults and their families.
“In certain situations, it’s actually possible to have both [Medicare and Medicaid]. This is called dual eligibility for Medicare and Medicaid.” – Jen Teague
The numbers highlight how common dual eligibility is. In 2021, 13.1 million Medicare beneficiaries – about 1 in 5 – were dual-eligible. This demonstrates how significant this group is within the Medicare population, benefiting from the combined advantages of both programs.
Who Qualifies for Both Programs
To qualify for dual eligibility, individuals must meet the criteria for both Medicare and Medicaid. Medicare generally covers people aged 65 and older or those with certain disabilities. Medicaid eligibility, on the other hand, is based on income and asset limits, which vary by state.
For many, dual eligibility happens naturally over time. For example, someone already receiving Medicaid due to low income may automatically qualify for Medicare upon turning 65.
Since Medicaid rules differ by state, eligibility depends not only on federal guidelines but also on specific state requirements. What qualifies someone in one state might not apply in another, making it essential to understand local income and asset thresholds. This variation underscores the importance of knowing how full and partial dual eligibility translates into benefits.
Full vs. Partial Dual Eligibility
Dual eligibility comes in two forms: full-benefit dual eligibles and partial-benefit dual eligibles. Each offers a different level of assistance.
Full-benefit dual eligibles receive comprehensive coverage from both Medicare and Medicaid. This includes all standard Medicare benefits plus additional Medicaid services like long-term care, dental exams, hearing aids, and eyeglasses. Medicaid also covers costs such as premiums, copays, coinsurance, and deductibles.
In 2021, 4.6 million full-benefit dual eligibles on SSI accounted for 47% of this group. This connection between disability benefits and dual eligibility highlights the program’s role in supporting individuals with disabilities.
Partial-benefit dual eligibles, by contrast, receive more limited support. They qualify for Medicare Savings Programs (MSPs), which help with Medicare Part A and B premiums and sometimes cost-sharing. However, they don’t receive the broader medical benefits that full Medicaid offers.
Interestingly, 92% of partial-benefit dual eligibles qualify for Medicaid through MSPs, making these programs a key pathway for partial dual eligibility.
The Centers for Medicare & Medicaid Services (CMS) uses specific codes to classify dual eligibles. Codes 02, 04, and 08 indicate “full duals”, while 01, 03, 05, and 06 are used for “partial duals”. While these codes are mainly for administrative purposes, they determine the level of benefits a person receives.
With eligibility explained, the next step is navigating the application process.
How to Apply for Both Programs
Applying for dual eligibility involves separate processes for Medicare and Medicaid, as the two programs are managed independently, even though they coordinate benefits for dual-eligible individuals.
To apply for Medicare, visit the Social Security website. Many people are automatically enrolled in Medicare Part A when they turn 65 if they already receive Social Security benefits. However, enrolling in Part B and any additional coverage often requires active steps.
For Medicaid, you’ll need to apply through your state’s Medicaid agency. Since Medicaid is state-administered, the process and eligibility criteria vary widely. States that have expanded Medicaid under the Affordable Care Act may have different income thresholds compared to those that haven’t.
You can use HealthCare.gov to get a general idea of Medicaid eligibility based on income, but the final determination comes from your state’s Medicaid office. Reaching out directly to your local office is the most reliable way to understand your options.
Be prepared to provide documentation of your income, assets, and other financial details. Once approved, the system automatically coordinates Medicare and Medicaid benefits, ensuring you receive all the assistance you’re entitled to without needing to manage the integration yourself.
How Medicare and Medicaid Work Together
When you’re dual-eligible, Medicare and Medicaid work hand-in-hand to maximize your benefits and minimize what you pay out of pocket. These programs don’t compete; instead, they complement each other. Medicare covers your healthcare services first, and then Medicaid steps in to handle what’s left, like copays and deductibles, ensuring you get the care you need without unnecessary financial strain. Let’s break down how this partnership works to reduce costs and expand your coverage.
Medicare Pays First
In dual eligibility, Medicare always takes the lead as the primary payer. That means when you go to the doctor or receive other healthcare services, Medicare processes and pays the claims first. Medicaid then steps in as the secondary payer, covering costs Medicare doesn’t fully handle, such as copays, coinsurance, and deductibles. For many dual-eligible individuals, Medicaid even covers Medicare premiums for Parts A and B, eliminating those monthly costs altogether.
In 2021, around 95% of full-benefit dual-eligible individuals received their Medicare and Medicaid benefits through separate coverage plans. This payment structure ensures there are no gaps in coverage, offering significant financial relief.
Lower Costs for Dual Eligibles
Dual eligibility can mean substantial savings. Medicare spends twice as much on a dual-eligible person compared to someone who only qualifies for Medicare. Why? Because Medicaid doesn’t just pick up Medicare’s leftover costs – it also provides additional services that Medicare doesn’t cover, like hearing aids, eyeglasses, and dental care.
For those who are partially dual-eligible, the focus is on reducing Medicare-related expenses. Through Medicare Savings Programs (MSPs), Medicaid helps cover Medicare premiums and some cost-sharing, easing healthcare costs even without full Medicaid benefits.
“The right arrangement will unlock critical services as well as cost savings. It can mean the difference between just getting by – and truly getting and staying healthy.”
– Ryan Ramsey, NCOA Associate Director of Health Coverage and Benefits
Coverage Comparison Chart
Here’s a quick look at how Medicare and Medicaid coverage works together for dual-eligible individuals, highlighting the benefits:
| Service Category | Medicare Coverage | Medicaid Coverage | Dual Eligible Advantage |
|---|---|---|---|
| Hospital Care | Covers acute care; deductibles apply | Pays Medicare deductibles and coinsurance | No out-of-pocket hospital costs |
| Doctor Visits | Covers visits; 20% coinsurance | Pays Medicare coinsurance | No copays for appointments |
| Prescription Drugs | Part D coverage with copays | May cover Medicare copays and extra drugs | Lower or eliminated drug costs |
| Long-term Care | Limited skilled nursing coverage | Comprehensive nursing home and home care | Full long-term care coverage |
| Dental Care | No routine dental coverage | Routine dental exams and treatment | Access to dental services |
| Vision Care | Limited to medical eye conditions | Covers eyeglasses and routine eye exams | Complete vision care |
| Hearing Aids | No coverage | Covers hearing aids and exams | Full hearing care coverage |
| Transportation | No coverage for routine appointments | Medical transportation services | Rides to healthcare visits |
In 2021, the most common arrangement for dual-eligible individuals was traditional Medicare paired with Medicaid fee-for-service, covering 28% of this group. About 24% were enrolled in Medicare Advantage plans combined with Medicaid managed care, showing that different setups can work effectively.
It’s worth noting that in some states, Medicaid may limit payments for Medicare cost-sharing, which can result in lower provider reimbursements for treating dual-eligible individuals. While this doesn’t impact your coverage or costs, it might affect provider availability in certain areas.
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Dual Eligible Special Needs Plans (D-SNPs)
Navigating Medicare and Medicaid separately can feel overwhelming. That’s where Dual Eligible Special Needs Plans (D-SNPs) come in. These are specialized Medicare Advantage plans (Part C) designed for individuals who qualify for both programs. They simplify access by coordinating Medicare and Medicaid benefits, making healthcare management much easier.
What Are D-SNPs?
D-SNPs are built specifically for people who qualify for both Medicare and Medicaid. They integrate benefits to provide streamlined care and must include Part D prescription drug coverage. States decide which D-SNPs are available in their regions. These plans have grown significantly in popularity. In 2021, 29% of dual-eligible individuals were enrolled in a D-SNP, a threefold increase since 2011. The trend continued in 2022, with enrollment jumping from 3.8 million to 4.6 million beneficiaries – a 20% increase.
D-SNP Eligibility and Benefits
To enroll in a D-SNP, you generally need to:
- Be a U.S. citizen or lawful permanent resident.
- Qualify for Original Medicare (Parts A & B).
- Meet your state’s Medicaid income and asset requirements.
- Live in an area where D-SNPs are offered.
You can confirm dual eligibility by checking for both Medicare and Medicaid cards. Starting in 2025, a monthly Special Enrollment Period will allow eligible individuals to enroll in certain D-SNPs offered by their Medicaid insurer.
D-SNPs often go beyond standard Medicare benefits by including services like vision, dental, and hearing care – areas not typically covered by Medicare. Many plans also offer extras such as:
- Monthly credits for purchases.
- Transportation support.
- Gym memberships.
- Meal delivery.
- Personal care teams.
- Bathroom safety devices and in-home support services.
“One of the biggest benefits of a D-SNP is that it often comes with a care coordinator.”
– Laura Esslinger, vice president of Medicare Duals segment for Aetna
How D-SNPs Make Healthcare Easier
D-SNPs simplify healthcare by combining Medicare and Medicaid benefits into one plan. This reduces the administrative hassle of managing two separate programs. They also provide a single point of contact for all health and drug benefits. Care coordinators play a key role, helping members find in-network doctors, schedule appointments, arrange transportation, and access other services.
“The beauty of D-SNPs is that they integrate Medicare’s hospital and medical insurance with Medicaid’s additional benefits. This means your medical bills, prescription drug costs, and other healthcare expenses are coordinated under one plan. Instead of dealing with two separate programs that don’t always communicate well, D-SNPs streamline everything.”
– The Baldwin Group
By focusing on coordinated care, D-SNPs align all providers to minimize confusion and avoid overlapping treatments. These plans are designed with affordability in mind, often featuring low or zero monthly premiums and covering costs like copayments and deductibles. Their growing popularity underscores their value – D-SNPs accounted for about 16% of total Medicare Advantage enrollment in 2022, up from 11% in 2011. Additionally, the number of available D-SNPs grew by more than 16% from the previous year.
For families managing dual eligibility, D-SNPs offer a much-needed solution, easing administrative challenges while delivering comprehensive, coordinated care.
Resources for Caregivers and Families
Managing dual eligibility can feel like an uphill battle, especially when you’re already juggling caregiving responsibilities. As we’ve discussed, handling this process effectively requires both a solid strategy and the right support. Thankfully, there are several resources designed to help you navigate your options and make informed decisions for your aging loved ones.
ElderHonor: A Guide to Education and Support
ElderHonor is a platform dedicated to simplifying eldercare decisions, including understanding dual eligibility and healthcare coverage. Founded by David Moyer, the platform highlights a critical statistic: 20% of employees face caregiving responsibilities for aging parents. This makes accessible education and support systems more important than ever.
ElderHonor emphasizes proactive planning over last-minute crisis management. They offer flexible learning options through monthly or yearly memberships, featuring the Complete ElderHonor Toolkit. This toolkit dives into key topics like starting sensitive conversations about healthcare, managing estates, and planning for long-term care. It comes packed with lessons, short videos, 30 assessments, and worksheets to guide families through the process.
“The goal of ElderHonor is to provide you knowledge to make confident decisions about your parents as they age so you are not in crisis mode but have those conversations and make plans before they are needed.” – ElderHonor
By laying a strong educational foundation, ElderHonor empowers families to plan ahead and provide better support for their loved ones.
Planning Ahead for Dual Eligibility
Starting early is essential. Dual eligibles make up 15% of the Medicaid population but account for 39% of Medicaid spending. They also represent 21% of the Medicare population while contributing to 36% of its spending. These figures underscore the complex medical needs of this group. Resources like the Complete ElderHonor Toolkit can help families prepare for these challenges well in advance.
Support Systems for Caregivers
In addition to early planning, there are several free government programs aimed at supporting caregivers. For instance:
- State Health Insurance Assistance Programs (SHIPs): Offer free, personalized guidance on Medicare and Medicaid.
- Area Agencies on Aging: Provide local resources and caregiver support.
- Arizona Caregiver Resource Line: Assists Arizona families with information and connections to local services.
ElderHonor also offers its Empowered Caregiver Course and Community, which equips caregivers with the tools, knowledge, and emotional support needed to manage their responsibilities effectively. For more personalized help, the platform provides one-on-one family coaching sessions, offering tailored, real-time solutions to caregiving challenges.
“With practical guidance, expert insights, and a network of compassionate caregivers by your side, you’ll be better equipped to navigate the complexities of caregiving with confidence and grace.” – David Moyer, Founder, ElderHonor
For those feeling daunted by the dual eligibility process, it’s worth remembering that 13.7 million people in the U.S. are enrolled in both Medicare and Medicaid. As Jen Teague, NCOA Director for Health Coverage and Benefits, reassures:
“It may sound complicated, but don’t let that get in the way of applying for and enrolling in the benefits you deserve.”
The bottom line? Start planning early, take advantage of available resources, and don’t hesitate to seek guidance from professionals. Whether it’s through ElderHonor’s educational tools, SHIP counselors, or your state Medicaid office, the support you need is out there to help you make the best decisions for your loved ones’ care.
Conclusion
In the United States, 13.7 million people qualify as dual-eligible individuals. These individuals often face intricate health challenges, with 87% living on annual incomes below $20,000 and many managing significant medical conditions.
The dual-eligibility system is designed to address these challenges while also offering practical ways to reduce costs. Medicaid steps in to cover what Medicare doesn’t, such as premiums, copays, and additional services like dental, vision, and hearing aids. This support can mean the difference between manageable healthcare costs and overwhelming financial strain for countless families.
For caregivers, Dual Eligible Special Needs Plans (D-SNPs) streamline the process by combining benefits from both programs and offering care coordinators to help navigate the system.
Jen Teague from the National Council on Aging (NCOA) emphasizes the importance of seeking these benefits:
“It may sound complicated, but don’t let that get in the way of applying for and enrolling in the benefits you deserve.”
Families can also tap into a variety of resources, including ElderHonor’s educational tools, State Health Insurance Assistance Programs, and guidance from professionals, to ensure they get the support they need.
FAQs
What’s the difference between full-benefit and partial-benefit dual eligibility for Medicare and Medicaid?
Full-benefit dual eligibility means you’re entitled to all Medicaid benefits, including coverage for long-term care services. Additionally, it helps with Medicare costs, such as premiums, copayments, and deductibles. In contrast, partial-benefit dual eligibility offers limited Medicaid support, like assistance with Medicare premiums through programs such as Medicare Savings Programs, but does not extend to the full suite of Medicaid benefits.
Knowing your eligibility status is key to accessing the right care and financial support. For those navigating dual eligibility, options like D-SNPs (Dual-Eligible Special Needs Plans) can help streamline and coordinate your healthcare needs.
What are Dual Eligible Special Needs Plans (D-SNPs), and how can you find out if you qualify?
Dual Eligible Special Needs Plans (D-SNPs)
Dual Eligible Special Needs Plans, or D-SNPs, are specially designed for individuals who qualify for both Medicare and Medicaid. Generally, eligibility requires enrollment in both programs, which is often confirmed by having both a Medicare card and a Medicaid card. Additionally, you must be either a U.S. citizen or a lawful permanent resident.
These plans come with added perks, including coordinated care, customized health services, and help covering certain out-of-pocket expenses. Essentially, D-SNPs aim to fill the gaps between Medicare and Medicaid benefits. If you’re unsure about your eligibility, it’s a good idea to contact your state Medicaid office or Medicare for guidance tailored to your situation.
How can I apply for dual eligibility and ensure Medicare and Medicaid benefits work together?
If you’re looking to apply for dual eligibility, the first step is to make sure you’re enrolled in Medicare Part A and/or Part B. Then, you’ll need to meet the Medicaid income and asset requirements set by your state. You can typically submit your application through your state’s Medicaid office – whether online, in person, or by mail.
Once you’re approved, the programs work together automatically. This means Medicaid steps in to cover costs that Medicare doesn’t, reducing your out-of-pocket expenses and ensuring both programs provide smooth, coordinated coverage.