Dual Eligibility for Medicare and Medicaid: What It Means for You

Medicaid Planning
Jason Neufeld
July 1, 2022

The distinction between Medicare and Medicaid can be confusing. Because they sometimes both apply, it is important to have a firm understanding of both. Medicare and Medicaid dual eligibility can play a very important role in the services that you – or your loved one – receives, and having the professional legal counsel of an experienced Florida Medicaid planning attorney in your corner is paramount.

Medicare and Medicaid Dual Eligibility

Because Medicare and Medicaid involve both state and federal governance, they are as complicated as you likely imagine. It is important to understand that Medicare and Medicaid are distinct programs and that some people are entitled to both.

Medicare is the federal government’s health insurance program that applies to people in the following categories:

  • Those who are over the age of 65
  • Younger people with certain kinds of disabilities
  • People who are afflicted with end-stage renal disease (ESRD), which is a permanent kidney failure that requires either a transplant or dialysis

Medicaid provides healthcare coverage for many Americans in financial need. Those eligible can include any of the following who meet certain asset and income criteria:

  • Adults, including elderly adults (and younger adults who are also disabled)
  • Children
  • People with disabilities
  • Pregnant women

Medicaid is funded by both the federal government and the state in which you live, making it exceptionally challenging to qualify without experienced legal guidance on your side.  

Understanding Dual Eligibility

Those who are eligible for both Medicare and Medicaid are considered to have dual eligibility. To qualify for dual eligibility, the following must apply:

  • You are enrolled in Medicare Part A (hospital care) or Medicare Part B (medical insurance). Alternatively, you can be enrolled in Medicare Part C, which is Medicare Advantage and which generally covers Part A, Part B, and – sometimes – Part D (prescription drug coverage). Medicare Advantage is managed by private insurance companies (that are approved by the federal government).
  • You are enrolled in either Medicaid’s full coverage or in Medicaid’s Medicare Savings Program. 

Medicaid’s comprehensive coverage incorporates all the following:

  • Coverage for doctor visits
  • Coverage for both inpatient and outpatient hospital services
  • Coverage for lab services
  • Coverage for X-rays
  • There are higher level Medicaid Programs that cover long-term care needs:
  • ICP: Provides coverage for nursing home care 
  • Medicaid Waiver: provides coverage for ALF care and in-home personal care assistance. 

How Medicare and Medicaid Dual Eligibility Works

It’s naturally beneficial to be covered by both Medicare and Medicaid. You can expect to receive more comprehensive healthcare coverage and to pay less out of your own pocket for the services that you receive. Dual eligibility coverage follows the following parameters:

  • For those medical expenses that are covered by Medicare, Medicare is the primary payer, which means that it is always the first to pay.
  • If Medicare does not cover the full range of expenses, the secondary payer, which is Medicaid, kicks in to cover whatever medical costs remain (as long as the expenses in question are covered by Medicaid, to begin with).

It is important to note that Medicaid covers some expenses that Medicare does not, including personal care assistance in the home and long-term nursing home care, which Medicare generally limits to only 100 days of total coverage. 

Long Term Care

Generally, the benefits of dual eligibility are most relevant when long-term care is required. 

Medicare Coverage

When it comes to long-term care expenses, you can expect your Medicare coverage to address all the following:

  • Up to 100 days of coverage per health issue
  • The full cost of your first 20 days of long-term care
  • 80 percent of your long-term care expenses for days 21 through 80
  • All medications covered under your Medicare Part D or private plan

With Medicare, you are responsible for covering your copayments and any medical supplies that are not covered. 

Medicaid Coverage

With Medicaid, on the other hand, you can expect all the following in terms of coverage for medical care:

  • Unlimited coverage (once you’ve qualified)
  • Coverage for all medications
  • Coverage for all medical supplies
  • Coverage for your Medicare copayments
  • Payment of your Medicare Part B Premium (so you’ll see extra cash in your bank account).

With dual eligibility, the coverage you receive is exceptionally comprehensive, but obtaining dual coverage tends to be exceptionally challenging. 

An additional service that we offer, for our clients who we help obtain dual-enrollment eligibility, is to help review your doctors, medications and to choose / enroll in a plan to provide the best health coverage for your individual needs. 

An Experienced Florida Medicaid Planning Attorney Can Help You Establish Medicare and Medicaid Dual Eligibility

If you or a family member requires Medicare and Medicaid dual eligibility, it is an important matter that requires careful legal attention. Because covering your long-term healthcare needs can prove financially devastating, establishing dual eligibility is critical, and a seasoned Florida Medicaid planning attorney can help you effectively and efficiently strategize your surest path forward. Your case is important to you and your family’s future, so you should not wait to reach out and contact or call us for more information about how we can help you today.

Jason Neufeld
Jason is committed to assisting and protecting the most vulnerable members of society, through his substantial legal work with the elderly.