What does it mean to be dual-eligible?

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What Does Dual-Eligible Mean?

As you might have guessed, dual-eligibility is a status of being eligible for two things – and in the case of Medicare and healthcare insurance, this means benefitting from both Medicare and Medicaid.

Medicare and Medicaid both deal with healthcare in the United States, more specifically with supporting individuals financially with their medical and healthcare needs and expenses. Beyond that, however, the two differ hugely – with Medicare covering those over 65 or living with an eligible disability, while Medicaid is largely based on income when it comes to eligibility.

From here, it starts to become a little clearer how one can be dual-eligible and thus benefit from both Medicare and Medicaid.

How Does Dual-Eligibility Work?

If you hit the eligibility criteria for Medicare, and also have a household income that is low enough to render you eligible for Medicaid additional support, then you are what we call dual-eligible. In practice, this means that any expenses you have to pay as premiums, deductibles, and uncovered bills outside of your Medicare coverage can be paid for with the support of Medicaid – for example, the out-of-pocket costs which must be paid by the beneficiary under a standard Medicare package agreement.

The Federal government operates and determines who is eligible for Medicare, funding the program across the United States. Meanwhile, Medicaid is partially owned by the state and so eligibility and coverage can differ from state to state. This means that to become dual-eligible you must meet the criteria of both programs in the state where you live.

There are a couple of different levels of support you can receive with dual-eligibility.

If you are “full dual-eligible”, you are enrolled in Medicare and also receive full Medicaid benefits. This means that Medicaid will cover the cost of any care services or medical services that Medicare does not cover.

If you are “partial dual-eligible” you are enrolled in Medicare and receive assistance from Medicaid to pay for Medicare premiums and copayments

Do I Have A Say In How My Dual-Eligibility Works?

Those who are eligible for Medicare and Medicaid do have a few options regarding how their care and support is delivered; largely depending on which kind of Medicare package they have decided to sign up for.

Those with Original Medicare will find that their Medicaid covers everything not included with Medicare.

Those with Medicare Advantage will find that again, Medicaid covers everything not included with Medicare – though in this case, the extent of Medicare cover is more comprehensive.

Medicaid Managed Care is state-specific with larger control and management over how the Medicare and Medicaid programs interact. In these instances, beneficiaries have a chance to receive more coordinated care and support in a way that best utilizes their two insurance covers.

If you think you may be dual-eligible, or want to discuss your options and next actions further, our team at Bobby Brock Insurance are always on hand to help and guide newly eligible beneficiaries.

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Justin Brock

President & CEO of Bobby Brock Insurance