Dually Eligible for Medicare and Medicaid: Understanding Your Coverage Options
If you qualify for both Medicare and Medicaid, you are considered “dually eligible.” This means you can get help paying for your health care costs from both programs. Being dually eligible can help you save money and get more benefits. Here’s what you need to know about your choices if you are dually eligible.
What Does It Mean to Be Dually Eligible?
Dually eligible individuals are people who meet the requirements for both Medicare and Medicaid. Medicare is a federal health insurance program for people age 65 and older, or for younger people with certain disabilities. Medicaid is a joint federal and state program that helps with medical costs for people with limited income and resources.
If you are dually eligible, Medicare is your primary payer. This means Medicare pays first for your covered services, and Medicaid may cover costs that Medicare doesn’t, such as premiums, deductibles, coinsurance, and some services not covered by Medicare.
Coverage Options for Dually Eligible Individuals
If you have both Medicare and Medicaid, you have several coverage options:
- Original Medicare (Parts A and B) with Medicaid: You can use your Original Medicare coverage for hospital and medical services. Medicaid may help pay for Medicare premiums, deductibles, and coinsurance. Medicaid may also cover some services that Medicare doesn’t, such as long-term care.
- Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs): These are special Medicare Advantage plans designed specifically for people who are dually eligible. D-SNPs coordinate your Medicare and Medicaid benefits and may offer extra services, such as care coordination, dental, vision, and hearing coverage, and transportation to medical appointments.
- Medicare Prescription Drug Coverage (Part D): If you have Medicare and Medicaid, you’re automatically eligible for Extra Help, a program that helps pay for your prescription drug costs. You can enroll in a standalone Part D plan or get drug coverage through a Medicare Advantage plan.
What Does Medicaid Cover If I Have Medicare?
Medicaid can help pay for costs that Medicare doesn’t cover, including:
- Medicare premiums, deductibles, and coinsurance
- Long-term care services (such as nursing home care)
- Some home and community-based services
- Dental, vision, and hearing services (coverage varies by state)
How to Enroll in a Dual Eligible Special Needs Plan (D-SNP)
To enroll in a Dual Eligible Special Needs Plan, you must:
- Have both Medicare Part A and Part B
- Have full Medicaid benefits (or certain levels of Medicaid assistance)
- Live in the plan’s service area
You can compare D-SNPs available in your area using the Medicare Plan Finder tool or by contacting your State Health Insurance Assistance Program (SHIP).
What Happens If You Lose Medicaid Eligibility?
If you lose Medicaid eligibility, you may lose some of the extra benefits provided by your D-SNP. You’ll have a Special Enrollment Period to switch to another Medicare Advantage plan or return to Original Medicare.
Where Can You Get Help?
If you’re dually eligible, it’s important to understand your options and get help choosing the right coverage. You can contact your local Medicaid office, State Health Insurance Assistance Program (SHIP), or the Medicare hotline at 1-800-MEDICARE for assistance.
Key Takeaways
- Dually eligible individuals can get help with health care costs from both Medicare and Medicaid.
- You can choose Original Medicare with Medicaid, or enroll in a Dual Eligible Special Needs Plan (D-SNP).
- Medicaid may cover costs and services that Medicare doesn’t.
- Get help from SHIP, your local Medicaid office, or Medicare to understand your options.
Understanding your options as a dually eligible individual can help you get the most out of your health care coverage. Take the time to learn about your choices and reach out for help if you need it. The National Council on Aging recommends using resources like SHIP, your local Medicaid office, or the Medicare hotline to get answers to your questions and find the best plan for you.