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Are You Dual Eligible?

Written by Evens Stevenson

When it comes to health care cost assistance for seniors, the U.S. government offers two primary programs. These are Medicare and Medicaid. In many cases, a person will be covered under one program or the other. There are, however, situations where an individual may be able to qualify for both programs at the same time.

Understanding Medicare and Medicaid can be difficult. There are dozens of different terms, rules, and exceptions that you have to keep straight. If you think or know that you’re eligible for both programs, which can add another confusing component to your coverage. It’s vital that you’re getting the coverage that you need.

Medicare and Medicaid

Before explaining dual eligibility for each program, we are going to outline each program and what they cover. It’s vital that you understand the bedual eligibility for medicare and medicaidnefits of the programs and what each of them will be providing if you are dual eligible.

For Medicare Part A, you’ll receive assistance if paying for hospitalization costs. The other part of original Medicare, Medicare Part B provides for doctor’s fees, lab fees, durable medical equipment, outpatient services, and much more. There are two other parts of Medicare, Medicare Part C and Medicare Part D that are optional and they provide additional coverage that is given with parts A and B. There are also Medigap Supplemental Plans available to buy, such as Medicare Part F, it provides the most coverage. Supplemental plans add an extra expense every month but they essentially cover all that original medicare does not.

Medicaid is a little different. This program is ran by each state, which means that each program could look a little different depending on which state that you live in. While each state can provide additional coverage, there are some core benefits that they are required to provide. Some of these benefits include home health services fees, nursing facility service fees, inpatient and outpatient hospital expenses, and much more.

Both of these programs are excellent resources that ensure that people are getting the health care that they deserve. As you can see, both of these programs have some overlap in what they cover for health care expenses. It’s common that these two programs get confused.

What is Dual Eligible?

The term dual eligible refers to those individuals who are qualified to receive benefits from both Medicare and Medicaid. These individuals meet the eligibility requirements for both programs – and because of this, they are also enrolled in both.

It is estimated that in the United States today, there are in excess of 9 million individuals who are dual eligible. These individuals primarily consist of either seniors who have low incomes, or of younger people who have low income and assets as well as certain types of disabilities. It is also estimated that those who are dual eligible account for approximately 18 percent of all Medicaid enrollees.

Dual eligible individuals get all the benefits of Medicaid and reduced Medicare costs. Such individuals are required to meet various income and asset requirements, and they must also be eligible for Medicare Part A and / or Medicare Part B, as well as one of the following Medicaid programs:

  • Full Medicaid, or
  • Medicaid Special Needs Plans, which include the following four programs:
  • The Qualified Medicare Beneficiary (QMB) Program
  • The Specified Low-Income Medicare Beneficiary (SLMB) Program
  • The Qualifying Individual (QI) Program, and
  • The Qualified Disabled Working Individual (QDWI) Program

A dual eligible individual is allowed to choose his or her coverage under FFS Medicare or under a Medicare Advantage plan. The dual eligible individual’s services will be paid first by Medicare. This is because Medicaid is always the payer of last resort. Medicaid may, however, pay the cost of the person’s prescription drugs, as well as the cost of other types of care that is not covered via Medicare.

Qualifying as a Dual Eligible

To qualify as a dual eligible, there are certain criteria that an individual must meet. These factors generally include the following:

  • Low income. In most cases, in order to qualify as being a dual eligible, an individual must have an annual income that is at or below the poverty level.
  • Low assets / resources. In addition, the individual or couple must also have a low amount of assets. In situations with married couples, if one of the spouses is to qualify, there are certain rules that both of the spouses must follow.
  • Fair or poor health. The individual must also be either in fair or poor health. In certain cases, the individual may be required to be residing in a skilled nursing home facility in order to qualify as a dual eligible.

*Note: If a current Medicare enrollee has income and / or assets that are just slightly above the federal poverty level, it may be possible for the individual to qualify for some limited Medicaid assistance. However, full benefits may not be available.

If you apply for both programs, you can contact your local Medicare or Medicaid offices and they can give you further assistance in applying for the programs.

Contact us at anytime with your questions. We would be happy to clear up any confusion and get you the coverage you want. Our agents are dedicated to making sure that nobody goes without health care coverage that they are eligible for. Any confusion or misunderstanding could lead to a gap in coverage that could leave you with hospital bills that you’re responsible for paying for yourself.

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