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Medicare and Medicaid Dual Eligibility

Medicare Made Easy

Medicare and Medicaid Dual Eligibility: Medicare D-SNP (Dual-Eligible Special Needs Plan) Eligibility & Enrollment

What is Medicaid?

Like Medicare, Medicaid is a health care coverage program funded by the federal government. It was established to help low-income individuals access health care coverage. Unlike Medicare, however, Medicaid is partially funded by state governments. This means that states have the flexibility to design their Medicaid programs to best meet the needs of their residents, as long as the program meets the minimum federal guidelines. As a result, Medicaid eligibility, services, and cost-sharing (the amount you pay alongside your insurance) policies will vary state-by-state, while the Medicare program is generally consistent across all states.

Medicare beneficiaries who are also eligible for Medicaid are considered dual-eligible. If you are Medicare dual eligible, you may qualify for a Medicare D-SNP (Dual Special Needs Plan), which is a type of Medicare Advantage plan.

Can you have Medicare and Medicaid at the same time?

Medicare and Medicaid are both public health insurance programs. If you are dual-eligible, you can have both Medicare and Medicaid coverage at the same time.

Two of the key differences between Medicare vs. Medicaid include:

  • Medicare is for people age 65 and over and for certain people under 65 who have a qualifying disability. Medicare eligibility is consistent for everyone across the U.S., no matter what state you live in.
  • Medicaid is for people of any age who meet certain income qualifications. Medicaid is administered by state governments, and eligibility requirements can differ between states.

Who is dual-eligible for Medicare and Medicaid?

To be Medicare dual eligible, you have to meet the requirements for Medicare and your state’s Medicaid program.

To be eligible for Medicare, you must:

  • Be at least 65 years old or have a qualifying disability
  • Be a U.S. citizen or permanent legal resident
  • Be eligible for benefits through Social Security or the Railroad Retirement Board

Generally speaking, Medicaid provides health insurance to low-income individuals and families, children, and pregnant women. The best way to find out if you are eligible for Medicaid is to visit your state’s Medicaid website.

If you’re eligible for Medicaid and want to find out if you’re also eligible for a dual-eligible Medicare Medicaid plan, you can call speak with one of our licensed insurance agents to find out if you’re eligible. An agent can help you compare the plans that are available where you live and find out what they may cover, which could include benefits like prescription drugs and other services.

What type of coverage do you get if you are dual-eligible for Medicare and Medicaid?

There are two levels of coverage for beneficiaries who are dual-eligible:

  • Full dual eligible
    Full dual-eligible refers to those who receive full Medicaid benefits and are also enrolled in Medicare.

    People who are fully dual eligible typically receive Supplemental Security Income (SSI) benefits, which provide cash assistance for basic food and housing needs.

    Qualifying as full dual eligible is based on your assets, which include checking and savings accounts, stocks, real estate (other than your primary residence), and vehicles (if you own more than one).

  • Partial dual eligible
    Partial dual eligibility includes those who receive assistance from Medicaid in order to help pay for Medicare costs such as premiums, coinsurance, or deductibles.

    Partial dual eligibles fall into one of four categories of eligibility for Medicare Savings Programs.

A Medicare Savings Program (MSP) is a federally funded program administered within each state that helps lower-income people pay for Medicare premiums, deductibles, copayments, and coinsurance.

The four Medicare Savings Programs are outlined below.

Qualified Medicare Beneficiary (QMB) Program

This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments.

Eligibility requires:

  • Income of no more than $1,094 per month for an individual in 2021, or $1,472 per month for a married couple
  • Resources of no more than $7,970 for an individual in 2021, or $11,960 for a married couple

Specified Low-Income Medicare Beneficiary (SLMB) Program

The SLMB program helps pay for Medicare Part B premiums.

Eligibility requires:

  • Income of no more than $1,308 per month for an individual in 2021, or $1,762 per month for a married couple
  • Resources of no more than $7,970 for an individual in 2021, or $11,960 for a married couple

Qualifying Individual (QI) Program

Like the SLMB, the Qualifying Individual program helps pay for Part B premiums.

Eligibility requires:

  • Income of no more than $1,469 per month for an individual in 2021, or $1,980 for a married couple
  • Resources of no more than $7,970 for individuals in 2021, or $11,960 for married couples

Qualified Disabled Working Individual (QDWI) Program

The QDWI program helps pay for the Medicare Part A premium for certain people who meet one of the following criteria:

  • Have a disability but are still working
  • Lost their premium-free Part A coverage when they returned to work
  • Are not receiving medical assistance from their state
  • Meet the income and resource limits below
    • Income of no more than $4,379 per month for an individual in 2021, or $5,892 for a married couple.
    • Resources of $4,000 for an individual in 2021, or $6,000 for a married couple.

The income and resource limits listed above may increase in 2022. If your income and resources are slightly higher, you should still apply.

Medicare Dual Eligible Special Needs Plans (D-SNPs)

Another type of coverage that may be available to dual-eligible beneficiaries (depending on where you live) is a Medicare Dual Eligible Special Needs Plan (D-SNP).

A Medicare special needs plan is a certain type of Medicare Advantage plan that is designed for people with specific health conditions or circumstances.

A D-SNP is built for the specific needs of dual eligibles. All Medicare SNPs (including Medicare D-SNPs) will provide prescription drug coverage.

How do Medicare and Medicaid work together?

For dual-eligible beneficiaries, Medicare serves as the primary payer, and Medicaid acts as the secondary payer.

That means Medicare is the first to pay for covered services and items, and then Medicaid will help pay some or all of your remaining costs.

What is PACE for Medicare and Medicaid?

Another Medicare and Medicaid program is PACE or Programs of All-Inclusive Care for the Elderly.

PACE helps older Medicare beneficiaries to seek health care within their community, in their home, and at PACE facilities.

Some of the things that can be covered by PACE include:

  • Adult day primary care
  • Dental care
  • Emergency services
  • Home care
  • Hospital care
  • Lab and X-ray services
  • Meals
  • Medical specialty services
  • Nursing home care
  • Nutritional counseling
  • Occupational therapy
  • Physical therapy
  • Prescription drugs
  • Preventive care
  • Respite care
  • Social work counseling
  • Caregiver training
  • Transportation to a PACE facility when medically necessary

PACE is not strictly restricted to Medicare dual-eligible beneficiaries. You may be eligible for PACE with only Medicare or only Medicaid (or both).

However, you must meet all of the following conditions:

  • Be at least 55 years old
  • Live in the service area of a PACE organization
  • Require a nursing home-level of care
  • Be able to live safely in the community with help from PACE

What is CHIP?

CHIP is a Medicaid program for children and stands for Children’s Health Insurance Program.

CHIP benefits vary by state, but they generally include EPSDT, or Early and Periodic Screening, Diagnostic and Treatment services. This coverage is designed to ensure children receive proper early detection and related care so that health problems may be averted or diagnosed as early as possible.

CHIP programs in all states must provide well-baby and well-child care, dental coverage, behavioral health care, and vaccines.

CHIP serves uninsured children up to age 19 in families that earn too much money to qualify for Medicaid but still have trouble affording care.

What is Medicare Extra Help?

Extra Help is a federal program that helps pay for out-of-pocket costs related to Medicare prescription drug coverage. Extra Help is also known as the Medicare Part D Low-Income Subsidy (LIS)

The assistance that Medicare Extra Help may provide includes:

  • Help to pay Part D premiums
  • Lowered out-of-pocket costs of prescription drugs
  • An annual Special Enrollment Period to enroll in a Part D plan or switch to a new one
  • Elimination of Part D late enrollment penalties

You automatically qualify for Extra Help if you are enrolled in Medicaid, Supplemental Security Income, or a Medicare Savings Program.

You may still qualify for Extra Help if you are not enrolled in any of those programs but still have income and assets below a certain limit.

Find Medicare Dual-Eligible Special Needs Plans in your area

There may be Medicare D-SNPs available where you live, though they aren’t as widely available as other types of Medicare Advantage plans.

An Ashford Insurance licensed insurance agent can help you explore your Medicare Advantage plan options. Compare the plans that are available and find out what they may cover, which could include benefits like prescription drugs or dental care.

Remember, plan benefits can change from year to year. Make sure you understand how a plan works before you join.

Ashford Insurance Agents can also assist you in enrolling in Medicaid and/or Medicare, call today 817-952-3153.

Need help? Call us for an appointment at (817) 952-3153

Sarah began working in the Texas healthcare industry in 2001, where she worked for many years with elderly Alzheimer and Dementia patients. From there she worked as a Group Benefits Administrator with a local healthcare company in the Human Resource Department for a period of 10 years. Since then, she has decided to work in the Texas Medicare insurance industry full time and has joined the family business, Ashford Insurance, as a Texas Medicare Insurance Agent.

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