There is dual eligibility for people who qualify for both Medicare and Medicaid programs, since both have different requirements and different coverages, designed for populations with problems of access to health care. On the one hand, Medicare is a federal health insurance program for people over the age of 65, some younger people with disabilities, and people with end-stage kidney disease.
On the other hand, and quite different from the Medicare program, Medicaid is a jointly financed program between the federal government of the United States, and the different states in which it operates. It provides health coverage to people with limited income and resources, and covers a wide range of health care services, including doctor visits, hospitalization, long-term care and more.
Differences Between Medicare and Medicaid
Dual eligibility means that you can qualify for both Medicare and Medicare coverage, on both counts, completely. This helps you cover the costs of health care getting the benefits of both programs combined. There are multiple ways to qualify and be approved for the dual eligibility of Medicare and Medicaid, but, broadly speaking, a person qualifies for Medicare by turning 65 years of age or by having a disability at any age. The case of Medicaid is different, which depends on the income and requirements in your state of residence.
As explained here by the Centers for Medicare & Medicaid Services (CMS) Different types of coverage for beneficiaries are offered by the four fundamental components of Medicare. Part A, called Hospital Insurance, covers inpatient hospital services, skilled nursing facility (SNF) care, hospice services, and some home health services.
Medicare’s Part B, known as Health Insurance, covers medical services provided by physicians, outpatient care, durable medical equipment (DME), laboratory and X-ray services, home health services, and numerous preventive services.
On the other hand, Part C, called Medicare Advantage (MA), is offered by Medicare-approved private insurance companies. These companies provide all the services of Parts A and B, and may offer prescription drug coverage and other supplemental benefits.
Finally, Part D, known as the Prescription Drug Benefit, provides prescription drug coverage through Medicare-approved private insurance companies. Medicare beneficiaries have the option of choosing between receiving Parts A and B services through Original Medicare, with the possibility of adding prescription drug coverage (Part D), or enrolling in an MA Plan that offers all these services in their service area, with the possibility of including prescription drug coverage in some plans.
Medicaid covers a wide variety of medical and care services, including doctor visits, hospitalization, prescription drugs, laboratory and X-ray services, long-term care in nursing homes, personal care, home and community services, and other necessary medical treatments.
Who Qualifies For Medicare and Medicaid Dual Eligibility?
Doubly eligible beneficiaries typically describe those with low incomes enrolled in both Medicare and Medicaid. This term includes beneficiaries enrolled in Medicare Part A, Part B, or both, and who receive full Medicaid benefits or only assistance with Medicare premiums or cost sharing through one of these Medicare Savings Program (MSP) eligibility groups:
- Qualified Medicare Beneficiary (QMB) Program: Covers Part A and Part B premiums, deductibles, coinsurance, and co-payments.
- Specifically Low-Income Medicare Beneficiary (SLMB) Program: Covers only Part B premiums.
- Qualified Individuals (QI) Program: Covers Part B premium only (individuals enrolled in this program have no other Medicaid eligibility).
- Qualified Working Disabled Individuals (QDWI) Program: Covers only the Part A premium for certain individuals under the age of 65 with disabilities who have returned to work.
First, Medica pays for eligible beneficiaries’ medical services doubly, as it is the primary payer for the items and services that both programs cover. Subsequently, Medicaid may be responsible for covering additional medical costs that Medicare does not cover, or partially covers, such as nursing home care, personal care, and services at home and in the community.
Beneficiaries’ coverage may vary by state. Some Medicaid Programs directly pay for care through Fee-for-Service (FFS) coverage, while others offer Medicaid through managed care models or other integrated models of care.
