
Medicare and Medicaid are two vital healthcare programs in the United States (US) designed to provide health coverage for different groups of people. While Medicare primarily serves seniors and certain disabled individuals, Medicaid is a needs-based program for low-income individuals and families. Some people qualify for both Medicare and Medicaid in the United States (US), making them “dual eligible.” Understanding who is eligible for both Medicare and Medicaid in the United States (US) is essential for ensuring access to comprehensive healthcare benefits.
What Is Medicare In The United States (US)?
Medicare is a federal health insurance program in the United States (US) primarily for individuals aged 65 and older. It also covers certain younger individuals with disabilities and people with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS).
Medicare in the United States (US) consists of four parts:
- Medicare Part A – Hospital Insurance (covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home healthcare services).
- Medicare Part B – Medical Insurance (covers doctor visits, outpatient care, preventive services, and medical supplies).
- Medicare Part C – Medicare Advantage (an alternative to Original Medicare that provides additional benefits through private insurance plans).
- Medicare Part D – Prescription Drug Coverage (helps cover the cost of prescription medications).
Medicare in the United States (US) is available to all eligible individuals regardless of income. However, out-of-pocket costs such as premiums, deductibles, and copayments may apply.
What Is Medicaid In The United States (US)?
Medicaid is a joint federal and state program in the United States (US) that provides health coverage to low-income individuals and families. Each state administers its Medicaid program based on federal guidelines, leading to variations in eligibility criteria and benefits across states.
Medicaid in the United States (US) covers essential healthcare services, including:
- Hospital stays and emergency care
- Doctor visits and preventive care
- Nursing home care and long-term care services
- Home health services
- Prescription drugs (varies by state)
Medicaid in the United States (US) is needs-based, meaning eligibility is determined by income and household size. Unlike Medicare, Medicaid may cover additional services such as vision, dental, and long-term care.
Who Is Eligible For Both Medicare And Medicaid In The United States (US)?
A person is eligible for both Medicare and Medicaid in the United States (US) if they meet the criteria for both programs simultaneously. These individuals are known as dual eligible beneficiaries.
To qualify as dual eligible in the United States (US), a person must:
- Be Eligible For Medicare – This includes individuals who are 65 or older, younger individuals with disabilities, or those with ESRD or ALS.
- Meet Medicaid Eligibility Requirements – Medicaid eligibility varies by state but is typically based on low income and limited assets.
Types Of Dual Eligible Beneficiaries In The United States (US)
Not all dual eligible beneficiaries receive the same level of Medicaid benefits. There are different categories of dual eligibility in the United States (US), including:
Full Dual Eligible
Individuals who qualify for full Medicaid benefits and Medicare coverage. Medicaid helps pay for Medicare premiums, deductibles, copayments, and may cover additional services not included in Medicare.
Partial Dual Eligible
These individuals receive Medicare Savings Programs (MSPs) but do not qualify for full Medicaid benefits. Medicaid assists with Medicare costs such as premiums and, in some cases, cost-sharing expenses. Categories under this include:
- Qualified Medicare Beneficiary (QMB) – Covers Medicare Part A & B premiums, deductibles, and copayments.
- Specified Low-Income Medicare Beneficiary (SLMB) – Covers Medicare Part B premiums.
- Qualified Individual (QI) – Assists with Medicare Part B premiums.
- Qualified Disabled and Working Individuals (QDWI) – Helps pay Medicare Part A premiums for certain disabled individuals.
Benefits Of Being Eligible For Both Medicare And Medicaid In The United States (US)
Individuals eligible for both Medicare and Medicaid in the United States (US) receive comprehensive healthcare coverage. Some key benefits include:
Cost Savings
Medicaid helps cover out-of-pocket costs for Medicare beneficiaries, including premiums, deductibles, and copayments.
Additional Healthcare Services
Medicaid covers services not typically included in Medicare, such as dental, vision, and long-term care.
Access To Special Medicare-Medicaid Plans
Some states offer Medicare-Medicaid Plans (MMPs) or Dual Eligible Special Needs Plans (D-SNPs), which provide coordinated healthcare benefits.
How To Apply For Both Medicare And Medicaid In The United States (US)
Applying For Medicare
To apply for Medicare in the United States (US):
- Online through the Social Security Administration (SSA) website.
- By phone at the SSA helpline.
- In person at a local Social Security office.
Applying For Medicaid
To apply for Medicaid in the United States (US):
- Visit your state’s Medicaid website.
- Apply through the Health Insurance Marketplace at HealthCare.gov.
- Contact a local Medicaid office.
Conclusion
Understanding who is eligible for both Medicare and Medicaid in the United States (US) is crucial for individuals seeking affordable healthcare. Dual eligible beneficiaries benefit from comprehensive coverage, cost savings, and additional healthcare services. If you believe you qualify, applying for both Medicare and Medicaid in the United States (US) ensures access to essential medical care.
Frequently Asked Questions
1. Who Is Eligible For Both Medicare And Medicaid In The United States (US)?
Individuals eligible for both Medicare and Medicaid in the United States (US) are known as dual eligible beneficiaries. To qualify, a person must meet the eligibility criteria for both programs simultaneously. Medicare eligibility applies to individuals aged 65 or older, those with certain disabilities, or those diagnosed with End-Stage Renal Disease (ESRD) or Amyotrophic Lateral Sclerosis (ALS). Medicaid eligibility is based on income and household size, and it varies by state. People who qualify for both programs receive comprehensive healthcare coverage, including hospital stays, doctor visits, long-term care, and prescription drugs. Dual eligible individuals may also receive financial assistance for Medicare premiums, deductibles, and copayments. This dual coverage ensures better healthcare access while reducing out-of-pocket medical expenses for low-income seniors and disabled individuals.
2. What Are The Income Requirements To Be Eligible For Both Medicare And Medicaid In The United States (US)?
Income requirements to be eligible for both Medicare and Medicaid in the United States (US) vary by state, as Medicaid eligibility is determined at the state level. Generally, individuals with income at or below 138% of the Federal Poverty Level (FPL) qualify for Medicaid under the Affordable Care Act (ACA) expansion. In 2024, this equates to approximately $20,120 per year for an individual and $41,400 for a family of four. Some states have stricter requirements, especially for those needing long-term care. Certain individuals may qualify under a Medicare Savings Program (MSP) if their income slightly exceeds the Medicaid limit. Medicaid also considers assets, with limits on savings and property ownership. People who qualify as “medically needy” may receive Medicaid benefits if they have high medical expenses that reduce their effective income.
3. How Does Being Eligible For Both Medicare And Medicaid In The United States (US) Affect Healthcare Costs?
Being eligible for both Medicare and Medicaid in the United States (US) significantly reduces healthcare costs. Medicare typically covers hospital stays (Part A), outpatient care (Part B), and prescription drugs (Part D). However, Medicare has premiums, deductibles, and copayments. Medicaid helps cover these costs, ensuring that dual eligible individuals have minimal out-of-pocket expenses. Additionally, Medicaid may cover long-term care, dental, vision, and transportation services that Medicare does not. Some dual eligible individuals are enrolled in Medicare Advantage Special Needs Plans (D-SNPs), which provide extra benefits. By coordinating Medicare and Medicaid, beneficiaries receive broader coverage with lower costs, ensuring access to necessary healthcare services without the financial burden of high medical bills.
4. What Benefits Do People Eligible For Both Medicare And Medicaid In The United States (US) Receive?
People eligible for both Medicare and Medicaid in the United States (US) receive comprehensive healthcare benefits, including hospital care, outpatient services, preventive care, and prescription drugs. Medicaid helps cover Medicare premiums, deductibles, and copayments, reducing out-of-pocket expenses. Additionally, Medicaid provides services not covered by Medicare, such as dental, vision, hearing aids, transportation to medical appointments, and long-term care. Some states offer home- and community-based services (HCBS), allowing individuals to receive care at home instead of in a nursing facility. Dual eligible individuals can also enroll in Dual Eligible Special Needs Plans (D-SNPs), which provide coordinated care with additional benefits. This dual coverage ensures that low-income seniors and disabled individuals have access to affordable and comprehensive medical care.
5. How Do I Apply If I Am Eligible For Both Medicare And Medicaid In The United States (US)?
To apply for Medicare, visit the Social Security Administration (SSA) website, call 1-800-772-1213, or apply in person at a local Social Security office. Enrollment typically begins three months before an individual’s 65th birthday or upon qualifying for disability benefits. Medicaid applications vary by state and can be submitted through the state Medicaid office, the Health Insurance Marketplace (HealthCare.gov), or a local Department of Human Services office. Dual eligible individuals may also apply for Medicare Savings Programs (MSPs), which help cover Medicare costs. Once approved for Medicaid, the state automatically determines eligibility for dual benefits, ensuring coordinated coverage between both programs. Individuals who qualify should regularly review their eligibility status since Medicaid requirements may change annually.
6. What Is The Difference Between Being Eligible For Medicare And Being Eligible For Both Medicare And Medicaid In The United States (US)?
Being eligible for Medicare alone means a person qualifies for federal health insurance based on age (65+) or disability but may have to pay premiums, deductibles, and copayments. In contrast, being eligible for both Medicare and Medicaid means that Medicaid provides additional financial assistance, covering cost-sharing expenses such as Medicare premiums, deductibles, and copayments. Additionally, Medicaid expands coverage beyond Medicare by offering long-term care, dental, vision, transportation, and in-home services. Dual eligible individuals receive better healthcare access with fewer financial burdens compared to those who only have Medicare.
7. Can A Person Lose Eligibility For Both Medicare And Medicaid In The United States (US)?
Yes, a person can lose eligibility for both Medicare and Medicaid in the United States (US). Medicare eligibility is permanent for most people once they qualify at age 65 or due to disability. However, Medicaid eligibility is based on income and assets, meaning individuals may lose Medicaid coverage if their financial situation improves. Some people lose Medicaid due to changes in state eligibility rules, failure to renew enrollment, or mistakes in paperwork. Those who lose Medicaid but still have Medicare may have to pay higher out-of-pocket costs unless they qualify for a Medicare Savings Program (MSP). If someone loses Medicaid eligibility, they can reapply if their financial situation changes or seek other assistance programs such as Extra Help for prescription drug costs.
8. How Does Medicaid Help People Who Are Eligible For Both Medicare And Medicaid In The United States (US)?
Medicaid helps people eligible for both Medicare and Medicaid in the United States (US) by covering costs that Medicare does not pay for. This includes:
- Paying Medicare premiums, deductibles, and copayments to lower out-of-pocket costs.
- Providing long-term care services, including nursing home care and home-based support.
- Offering dental, vision, and hearing coverage, which Medicare does not fully cover.
- Covering prescription drugs at lower costs through Medicaid or Medicare Part D assistance.
- Providing transportation to medical appointments for eligible individuals.
By combining benefits from both programs, dual eligible individuals receive more comprehensive healthcare coverage with minimal financial burden.
9. Are There Different Levels Of Eligibility For Both Medicare And Medicaid In The United States (US)?
Yes, there are different levels of dual eligibility for Medicare and Medicaid in the United States (US):
- Full Dual Eligible – Receives full Medicaid benefits and financial assistance for Medicare premiums, deductibles, and copayments.
- Partial Dual Eligible – Receives help with Medicare costs through a Medicare Savings Program (MSP) but does not qualify for full Medicaid benefits.
Medicaid eligibility levels depend on income, assets, and state regulations. Each category provides varying levels of financial assistance, ensuring that individuals get the maximum benefits they qualify for.
10. What Is The Medicare Savings Program For Those Eligible For Both Medicare And Medicaid In The United States (US)?
The Medicare Savings Program (MSP) helps people eligible for both Medicare and Medicaid in the United States (US) by covering Medicare premiums, deductibles, and copayments. There are four MSP categories:
- Qualified Medicare Beneficiary (QMB) – Pays for Medicare Part A and B premiums, deductibles, and copayments.
- Specified Low-Income Medicare Beneficiary (SLMB) – Covers only Medicare Part B premiums.
- Qualified Individual (QI) – Assists with Medicare Part B premiums, subject to available funding.
- Qualified Disabled and Working Individuals (QDWI) – Pays for Medicare Part A premiums for certain disabled individuals.
MSPs lower out-of-pocket expenses and ensure that low-income seniors and disabled individuals receive affordable medical care. People eligible for an MSP automatically qualify for Extra Help with Medicare prescription drug costs.
11. Do People Eligible For Both Medicare And Medicaid In The United States (US) Have To Pay Medicare Premiums?
No, most people eligible for both Medicare and Medicaid in the United States (US) do not have to pay Medicare premiums because Medicaid covers these costs through Medicare Savings Programs (MSPs). Specifically, the QMB, SLMB, and QI programs help pay for Medicare Part A and B premiums. In some cases, Medicaid also covers deductibles, copayments, and coinsurance for healthcare services. However, partial dual eligible individuals may still have some cost-sharing responsibilities. Medicaid coverage varies by state, so it’s essential for beneficiaries to check their state’s Medicaid program to understand the exact benefits.
12. What Is The Role Of State Medicaid Programs For Those Eligible For Both Medicare And Medicaid In The United States (US)?
State Medicaid programs play a critical role in helping those eligible for both Medicare and Medicaid in the United States (US) by:
- Paying for Medicare costs (premiums, deductibles, and copayments).
- Providing long-term care services, including nursing home care and home-based support.
- Covering additional medical services, such as dental, vision, and hearing aids.
- Offering transportation assistance for medical appointments.
Each state administers its own Medicaid program under federal guidelines, which means eligibility rules and benefits may vary. Some states offer waiver programs that expand services for individuals needing home or community-based care. Medicaid ensures that dual eligible individuals receive comprehensive coverage without financial hardship.
13. How Does Long-Term Care Work For Individuals Eligible For Both Medicare And Medicaid In The United States (US)?
Long-term care for individuals eligible for both Medicare and Medicaid in the United States (US) is primarily covered by Medicaid, as Medicare has limited coverage for long-term care. Medicaid pays for:
- Nursing home care for individuals who meet financial and medical eligibility.
- Home- and community-based services (HCBS), allowing individuals to receive care at home instead of a facility.
- Personal care assistance, including help with daily activities such as bathing, dressing, and eating.
Because long-term care is expensive, dual eligible individuals benefit from Medicaid’s financial assistance, ensuring they receive the necessary support without significant out-of-pocket costs. Each state has its own Medicaid long-term care eligibility rules, so individuals should apply through their state Medicaid office.
14. Do People Eligible For Both Medicare And Medicaid In The United States (US) Get Prescription Drug Coverage?
Yes, people eligible for both Medicare and Medicaid in the United States (US) get prescription drug coverage through Medicare Part D. Medicaid no longer covers prescription drugs for dual eligible beneficiaries, but Medicaid assists with Part D cost-sharing expenses. Eligible individuals are automatically enrolled in the Extra Help program, which helps pay for:
- Monthly premiums for Part D plans.
- Annual deductibles.
- Copayments for prescription drugs.
Medicare Part D plans vary, so beneficiaries can choose a plan that best fits their medication needs. Medicaid ensures that even the lowest-income individuals have affordable access to necessary medications.
15. How Can Someone Find Out If They Are Eligible For Both Medicare And Medicaid In The United States (US)?
To determine eligibility for both Medicare and Medicaid in the United States (US), individuals should:
- Check Medicare eligibility – Visit SSA.gov or call 1-800-772-1213.
- Check Medicaid eligibility – Visit their state Medicaid website or apply through HealthCare.gov.
- Apply for a Medicare Savings Program (MSP) – If income is slightly above Medicaid limits, MSPs may still provide financial assistance.
- Speak with a local Medicaid office or SHIP (State Health Insurance Assistance Program) – Experts can guide individuals through the application process.
Since Medicaid eligibility varies by state, applicants must review income and asset limits in their state to confirm qualification.
16. What Special Insurance Plans Are Available For Those Eligible For Both Medicare And Medicaid In The United States (US)?
Individuals eligible for both Medicare and Medicaid in the United States (US) can enroll in Dual Eligible Special Needs Plans (D-SNPs). These Medicare Advantage plans provide:
- Coordinated healthcare coverage by integrating Medicare and Medicaid benefits.
- Additional services, such as dental, vision, and wellness programs.
- Lower out-of-pocket costs, with Medicaid covering most expenses.
D-SNPs ensure seamless healthcare delivery, improving access to medical services while reducing financial burdens.
17. How Does Dual Eligibility Work For Veterans Who Are Eligible For Both Medicare And Medicaid In The United States (US)?
Veterans eligible for both Medicare and Medicaid in the United States (US) can use their VA benefits along with Medicare and Medicaid. The VA covers healthcare services at VA facilities, while Medicare and Medicaid cover non-VA medical care. Medicaid may also cover long-term care services, which the VA may not fully fund. Veterans should coordinate their benefits to ensure they receive comprehensive healthcare without unnecessary costs.
18. What Is The Difference Between Partial And Full Eligibility For Both Medicare And Medicaid In The United States (US)?
- Full dual eligibility: Individuals receive full Medicaid benefits along with Medicare, covering all medical costs.
- Partial dual eligibility: Medicaid only helps pay Medicare premiums and some cost-sharing expenses, but the individual does not receive full Medicaid benefits.
The level of assistance depends on income and asset limits, with full dual eligible individuals receiving more comprehensive healthcare coverage.
19. What Happens If A Person Eligible For Both Medicare And Medicaid In The United States (US) Moves To A Different State?
If a person eligible for both Medicare and Medicaid in the United States (US) moves to another state, they must reapply for Medicaid in the new state. Medicaid rules and eligibility vary, so benefits may change. However, Medicare coverage remains the same nationwide. Dual eligible individuals should contact their new state’s Medicaid office immediately to avoid gaps in coverage.
20. How Does Home Healthcare Work For Those Eligible For Both Medicare And Medicaid In The United States (US)?
Home healthcare for individuals eligible for both Medicare and Medicaid in the United States (US) is primarily covered by Medicare Part A and B for short-term skilled care, while Medicaid provides long-term home-based services. Medicaid may cover:
- Personal care assistance for daily activities.
- Nursing care at home.
- Homemaker services.
Many states offer Home- and Community-Based Services (HCBS) programs, allowing individuals to receive care at home instead of moving to a nursing facility. Medicaid ensures that those who need long-term care can stay in their communities while receiving necessary support.
Further Reading
- How Do I Qualify For Medicare In The United States (US)?
- How Do I Qualify For Medicare Advantage In The United States (US)?
- Who Is Eligible For Medicare Advantage In The United States (US)?
- How To Apply For Medicare Advantage Plans In The United States (US)
- What Are The Advantages And Disadvantages Of Medicare Advantage Plans In The United States (US)?
- Can I Switch Medicare Advantage Plans In The United States (US)?
- What Does Medicare Advantage Cover In The United States (US)?
- How Do I Choose The Best Medicare Advantage Plan In The United States (US)?
- What Are The Limitations Of Medicare Advantage In The United States (US)?
- How Does Medicare Advantage Compare To Medicaid In The United States (US)?
A Link To A Related External Article
Medicare and Medicaid: Dual eligibility