Medicare and Medicaid Dual Eligibility Programs

Welcome back to our third and final blog about the Medicare enrollment period which is beginning on October 15. In our first blog, we discussed Medicare and some of the issues and misunderstanding associated with it as well as explaining the infamous "donut hole". In our second, we looked at Medigap and Medicare Advantage Plans and hopefully provided some relevant information to assist those in need of a change or signing up for the first time with some assistance in making an informed choice.

Some may qualify for a blend of Medicare and Medicaid

In our previous blogs, we ended with a section and a link to state SHIP offices and because this information is so important, we will do the same here. SHIP offices are an invaluable resource for those choosing a Medicare plan. But before we get to that part of this week’s blog, let’s examine the dual eligibles – those who qualify for both Medicare and Medicaid coverage. Here’s a quick review of these programs separately.


Medicare is health insurance for people 65 or older, certain people under 65 with disabilities, and people of any age with End-Stage Renal Disease. Medicare consists of four different parts:

  • Part A – Hospital insurance (inpatient hospital care, inpatient care in a Skilled Nursing Facility, hospice care, and some home health services);

  • Part B – Medical insurance (physician services, outpatient care, durable medical equipment, home health services, and many preventive services);

  • Part C – Medicare Advantage (MA) (Medicare-approved private insurance companies provide all Part A and Part B services and may provide prescription drug coverage and other supplemental benefits); and

  • Part D – The Prescription Drug Benefit (Medicare-approved private companies provide outpatient prescription drug coverage).

Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help Program, which helps pay for monthly premiums, annual deductibles, and co-payments (click on the photo below to see if a senior you know may qualify);


The Medicaid Program is a joint venture funded at the Federal and State levels that pay for medical care for families and certain individuals with low incomes and/or limited resources. The Federal Government established guidelines which allow each state to:

  • Establish its own eligibility standards;

  • Determine the type, amount, length and scope of services;

  • Establish rates of payment for services; and

  • Oversee its own program.

This is why those who apply for Medicaid to assist with nursing home costs must be very careful in meeting the requirements and often require an elder law attorney's help as each state has different guidelines around qualifications. For instance, the Medicaid laws in Rhode Island, Massachusetts, and Connecticut are the same in some areas but different in others which is why navigating the Medicaid minefield may require professional assistance as one mistake on the application could result in a rejection and a loss of assets.

Basic illustration of both programs and where both programs come together

Dual Eligible Beneficiaries

“Dual eligible beneficiaries” is the term that describes individuals who are enrolled in both Medicare and Medicaid. Individuals must separately qualify for both Medicare and Medicaid coverage to become dual-eligible beneficiaries. Roughly half of the dual eligibles first qualify for Medicare based on disability (compared with 17 percent of Medicare beneficiaries who are not dual eligibles) and roughly half qualify when they turn 65.

Medicaid’s eligibility rules vary across states, as we indicated earlier, but most dual eligibles qualify because they receive Supplemental Security Income (SSI) benefits, need nursing home care or have other high medical expenses, or meet the eligibility criteria for the Medicare Savings Programs (MSP) categories. These categories are as follows:

  • Qualified Medicare Beneficiary Program (QMB) – This helps pay for Part A and/or Part B premiums, deductibles, co-insurance, and co-payments;

  • Specified Low-Income Medicare Beneficiary Program (SLMB) – This program helps pay for Part B premiums;

  • Qualifying Individual Program (QI) – Also helps pay for Part B premiums; and

  • Qualified Disabled Working Individual Program (QDWI) – This pays the Part A premium for some people who qualify that have disabilities and are still working.

Now, this alphabet soup of programs comes with a number of qualifiers and disqualifiers. Rather than get into this, we are providing a link to the federal government site which can explain each one of these much better than we could in a blog format. Here it is:

There is also a Dual Eligible Special Needs Plan. This plan is a special type of Medicare Advantage plan that is individually designed to provide specialized benefits, provider networks, and medications/pharmacies to meet the unique needs of the individual.

To be eligible for the Special Needs plan, the individual must:

  • Be eligible for both Medicare and Medicaid;

  • Live in a service area of a Dual eligibility Special Needs plan;

  • Not have end-stage renal disease (unless a waiver is granted);

  • Click on the photo below to learn more.

Enrollment Periods

Unlike others on Medicare, dual-eligible individuals have much more flexibility to make changes to their Medicare coverage throughout the year. If someone is a dual eligible, there is a Special Enrollment Period available on an ongoing basis which can be used to:

  • Switch from Original Medicare to a Medicaid Advantage plan

  • Switch Medicare Advantage plans;

  • Disenroll from a Medicare Advantage plan and return back to original Medicare.

For an individual who is dual eligible, they can use this Special Enrollment Period to enroll in, switch, or disenroll from a Dual Eligible Special Needs plan at any time. For instance, if an individual loses their Medicaid eligibility, they get a Special Enrollment Period that allows them to switch Medicare Advantage plan or return to Original Medicare. This special period starts the month the individual receives notice that they are no longer eligible for Medicaid services plus an additional two months. If an individual receives notice that they will lose Medicaid eligibility for the upcoming year, they can make these changes from January 1 to March 31.

Got all that? We know, quite confusing but information that those working in senior care facilities need to know and for those with senior family members who may be enrolling in Medicare for the first time or thinking about changing plans.

If you are confused as to whether a senior or someone with a disability qualifies for these services, click on our link below to go to a government site that can tell you what programs you may or may not qualify for.

Who Pays What?

With all these plans under dual eligibility, the question then becomes, who pays for what? Well, let’s try to explain this. Medicare-covered services that are also covered by Medicaid are paid first by Medicare because Medicaid is the payer of last resort. That’s government language that simply means that providers will get money from everyone else first and only collect from Medicaid if there is no one else to get money from.

Medicaid may cover the cost of care that Medicare may not cover or may partially cover, such as nursing homes, personal care, and community-based services. And because there are income and resource standards for full Medicaid eligibility, the federal government gives each state has the right to adjust those limits. Thus the importance of long-term care planning to avoid financial problems. Click here to explore Medicaid Planning with our office.

Before we move on to SHIP services, there are three other Medicaid programs that are available to qualifying Medicare beneficiaries in all states. The payments are made as we described previously with Medicare paying first and Medicaid paying second.

Other Medicaid Services and Plans

Like the other plans, we described earlier, if you meet the requirements in your state, you may qualify for one of these programs;

  • Age, blind and disabled Medicaid (ABD) – those with this plan have coverage for a broad range of services including doctor’s visits, hospital care, and medical equipment. However, ABD Medicaid may not provide appropriate coverage if long term care is needed. Click on the photo below for more information.

  • Medicaid home and community-based service (HCBS) waiver programs: these programs provide general health coverage and coverage for certain services to help you stay at home or in a community-based setting (for example, in an assisted living facility). Covered services may include personal care, homemaker services, case management, adult daycare, skilled nursing care, and therapy services. To qualify, you must meet state-specific functional eligibility criteria.

  • Institutional Medicaid – Includes coverage for nursing home services including room and board, nursing care, personal care, and therapy services.

SHIP Services

So once again, we want to close out our blog with information about the State Health Insurance Assistance Program (SHIP). SHIP provides Medicare beneficiaries with information, counseling, and enrollment assistance. Its mission is to strengthen the capability of grantees to support a community-based, grassroots network of local SHIP offices that assist beneficiaries with their Medicare-related questions.

SHIPs present and distribute information to groups and individuals to inform them on Medicare benefits, coverage rules, written notices and forms, appeal rights and procedures, and more. They also provide free, in-depth, one-on-one insurance counseling and assistance to Medicare beneficiaries, their families, friends, and caregivers.

SHIPs assist people in obtaining coverage through options that include the Original Medicare program, Medicare Advantage (Part C) Plans, Medicare Prescription Drug (Part D) Plans, and programs designed to help people with limited incomes pay for their health care, such as Medicaid, the Medicare Savings Program, and the Low-Income Subsidy. They can help people compare Medicare Supplemental (Medigap) insurance policies and explain how these and other supplemental insurance options (e.g., insurance plans for retirees) work with Medicare.

SHIPs also provide information on long-term care insurance and, when needed, refer beneficiaries to agencies such as the Social Security Administration and local Medicaid offices for additional assistance. Many SHIP counselors are volunteers who are trained and certified to help navigate systems for older adults and some people with disabilities.

We at Connelly Law Offices encourage you to contact your local SHIP office and make an appointment if you have insurance questions. You can find the SHIP offices in your state by clicking on the photo below:

We thank you for reading our series of blogs on Medicare and hope we have provided you with information to help you sort through the maze of the upcoming open enrollment period. If you liked this information, let us know with a like or a comment.

September 3, 2020 Edition of Southcoast Seniors

199 views0 comments

Recent Posts

See All