Understanding Medicare & Medicaid: Dual Eligibility and Differences

Summary Highlights from This Blog Post:

• The key differences between Medicare and Medicaid, including who qualifies and what services they provide.
• Shared services between both programs and how they work together.
• How individuals can qualify for both programs (dual eligibility) and maximize their benefits.

Medicare vs. Medicaid: What’s the Difference?

Medicare and Medicaid are both government-funded health insurance programs, but they serve different populations and have distinct coverage and eligibility requirements.

What is Medicare?

Medicare is a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS) and is funded by taxes, premiums, and general revenue. It is for those who are:

• Individuals aged 65 and older, regardless of income.
• Certain younger individuals with disabilities.
• People diagnosed with End-Stage Renal Disease (ESRD) or ALS (Lou Gehrig’s disease).

Medicare Coverage Includes:

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facility stays, hospice, and home health care.
• Part B (Medical Insurance): Includes doctor visits, outpatient care, preventive services, and durable medical equipment.
• Part C (Medicare Advantage): A private insurance alternative that combines Parts A and B, often including additional benefits like vision, dental, and prescription drug coverage.
• Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications.

What is Medicaid?

Medicaid is a joint federal and state program that provides healthcare coverage to low-income individuals and families. Eligibility is based on income and household size, with criteria varying by state.

Medicaid Coverage Includes:

• Hospital stays and doctor visits.
• Prescription drugs (coverage varies by state).
• Long-term care services, such as nursing home care and home health care.
• Preventive care, maternity care, and mental health services.

What Do Medicare and Medicaid Both Cover?

Although they are separate programs, they share some overlapping benefits, including:
✔️ Hospital stays and doctor visits
✔️ Emergency and urgent care services
✔️ Preventive care and screenings
✔️ Home health services
✔️ Certain prescription drugs (covered by Medicare Part D, with Medicaid coverage varying by state)

Dual Eligibility: Qualifying for Both Medicare & Medicaid

Some individuals qualify for both Medicare and Medicaid, making them “dually eligible beneficiaries.”

Who Qualifies for Dual Eligibility?

You may be dually eligible if you:
✔️ Meet Medicare’s age or disability criteria AND
✔️ Meet Medicaid’s income and asset limits (which differ by state).

Benefits of Being Dual Eligible:

• Medicaid helps cover Medicare premiums, deductibles, and copays, reducing out-of-pocket expenses.
• Medicaid provides additional services that Medicare does not, such as long-term nursing home care and certain home-based healthcare services.
• You may qualify for a Special Needs Plan (SNP), a type of Medicare Advantage plan specifically designed for dual-eligible individuals.

Final Thoughts

Understanding the differences between Medicare and Medicaid is crucial when selecting the right healthcare coverage. Dual eligibility ensures comprehensive coverage, minimizing healthcare expenses and ensuring access to essential medical services.

If you or a loved one may qualify for Medicare, Medicaid, or both, consider speaking with a Medicare specialist or visiting Medicare.gov and your state’s Medicaid office to explore your options. You can also call one of our Licensed Agents at Trusted Senior Specialists and we can help you navigate the enrollment process. There is no cost or obligation for a consultation! 

We are available Monday through Friday from 8 AM to 8 PM CST,
and on Saturday by appointment.
You can reach us by calling: 1-855-952-1941 TTY: 711
By calling this number you may be connected to a licensed agent.

Have questions about Medicare, Medicaid, or dual eligibility? Drop a comment below, and let’s discuss!