Medicare is the federal health insurance program in the United States for people age 65 and older. Medicaid is a joint federal and state program to help people with limited resources or income pay for medical costs. You may qualify for both.
According to Health Affairs, more than 12 million people, about 3% of the United States population, are enrolled in both Medicare and Medicaid.
Keep reading to learn more about dual eligibility, benefits, and state-by-state differences.
The terms Medicaid and Medicare are often confused since they are both government healthcare programs. They even sound extremely similar, but they are actually very different.
Medicare
Medicare is a government-funded medical insurance option that many older Americans use as their primary health insurance. It also covers people with certain disabilities and health conditions. Medicare is not free coverage — you’ll still pay deductibles, premiums, and copays for medical services.
Medicaid
Medicaid is a program that combines the efforts of the U.S. state and federal governments to assist households in low-income groups with healthcare expenses. These may include major hospitalizations and treatments as well as routine medical care. This care is often provided at low or no cost, depending on your income. Medicaid also offers benefits not typically covered by Medicare.
If you’re eligible for both Medicare and Medicaid, you’re considered a dual eligible beneficiary. Dual eligibility is typically determined by your age, any disabilities, and income.
Who pays first if you have dual eligibility?
Since Medicaid is generally the payer of last resort, Medicare pays covered medical services first for dual eligible beneficiaries.
If you have other coverage, such as employer group health plans or Medicare supplement plans (Medigap), that coverage will pay first and Medicaid last.
Medicaid may cover healthcare costs that Medicare only partially covers or may not cover at all, such as:
- home-based services
- personal care
- nursing home care
What are the state-by-state differences?
Benefits for dual eligible beneficiaries can differ based on your state of residence. Differences by state may include:
- Medicaid offered through Medicaid managed care plans
- fee-for-service Medicaid coverage
- plans that include all Medicare and Medicaid benefits
Federal law defines income and resource standards for full Medicaid and Medicare Savings Programs (MSP). States can raise the federally mandated limits at their discretion.
You’re also considered a dual eligible beneficiary if you’re enrolled in Medicare Part A or Part B and receiving cost-sharing through an MSP.
Below is a table summarizing the benefits and eligibility criteria for each of the different MSPs in 2024:
| MSP | Benefits | Eligibility |
|---|---|---|
| Qualified Disabled Working Individual (QDWI) program | pays the Part A premium for certain beneficiaries who are working and have certain disabilities | individual monthly income of $5,105 or less, individual resources limit of $4,000; married couple monthly income of $6,899 or less, married couple resources limit of $6,000 |
| Qualifying Individual (QI) program | assists in the payment of Part B premiums | individual monthly income of $1,715 or less, individual resources limit of $9,430; married couple monthly income of $2,320 or less, married couple resources limit of $14,130 |
| Qualified Medicare Beneficiary (QMB) program | assists in the payment of deductibles, premiums, coinsurance, and copayments for Part A, Part B, or both | individual monthly income of $1,275 or less, individual resources limit of $9,430; married couple monthly income of $1,724 or less, married couple resources limit of $14,130 |
| Specified Low-Income Medicare Beneficiary (SLMB) program | assists in the payment of Part B premiums | individual monthly income of $1,526 or less, individual resources limit of $9,430; married couple monthly income of $2,064 or less, married couple resources limit of $14,130 |
In addition to the Medicare savings programs, you also may be eligible for some of the following needs-based programs through Medicare:
- PACE (Program of All-inclusive Care for the Elderly): This is a Medicare-Medicaid joint program that provides medical and social services for people with significant needs who want to continue living at home
- Medicare’s Extra Help program: This program helps those with low incomes get the prescription drugs they need at reduced or no cost
Dual eligibility for Medicare and Medicaid means that you’re enrolled in Medicare and either:
- receiving full Medicaid benefits
- receiving assistance with Medicare premiums
- receiving cost-sharing through an MSP
If you’re a dual eligibility beneficiary, it’s likely that most of your healthcare costs are covered.