Medicare and Medicaid are two of the most important health insurance programs in the U.S.—but because their names are so similar, people often confuse them. What’s more, some individuals qualify for both at the same time. These individuals are known as dual-eligible beneficiaries.
Millions of Americans fall into this category, but many don’t fully understand how the two programs coordinate. If you’re eligible for both, combining these benefits can significantly reduce your healthcare costs and expand your coverage.
Let’s take a closer look at the key differences between Medicare and Medicaid and how they work together for dual-eligible individuals.
Medicare vs. Medicaid: What’s the Difference?
To understand how these programs coordinate, it helps to start with the basics.
What Is Medicare?
Medicare is a federal health insurance program primarily for people 65 and older, though younger individuals with certain disabilities or End-Stage Renal Disease (ESRD) may also qualify. The program is divided into four parts:
- Part A: Hospital insurance
- Part B: Outpatient and medical services
- Part D: Prescription drug coverage
- Part C (Medicare Advantage): A private plan that bundles Parts A, B, and usually D into one plan
Medicare is national in scope and offers uniform benefits regardless of your state.
What Is Medicaid?
Medicaid, on the other hand, is a joint federal and state program designed to help individuals and families with low income. It covers many of the same services as Medicare but may also include additional benefits such as long-term care, home health services, and transportation to medical appointments.
Each state administers its own Medicaid program, so eligibility and benefits vary depending on where you live. Income, assets, family size, and disability status all play a role in determining who qualifies.
What Does It Mean to Be Dual Eligible?
If you qualify for both Medicare and Medicaid, you’re considered dual eligible. This status allows you to access broader healthcare benefits at lower out-of-pocket cost.
Here’s how dual eligibility helps:
- Medicare covers your main healthcare needs like doctor visits, hospital stays, and outpatient care.
- Medicaid acts as a secondary payer, covering expenses that Medicare doesn’t, including premiums, copays, and deductibles.
- Medicaid may also cover services that Medicare excludes, like long-term care in a nursing home or extended home and community-based support.
Together, these two programs can provide highly comprehensive coverage—especially for individuals with chronic conditions or complex healthcare needs.
Special Plans for Dual Eligibles: What Is a D-SNP?
If you’re dual eligible, you may also qualify for a Special Needs Plan (SNP) specifically designed for people in your situation. These plans are called Dual Eligible Special Needs Plans (D-SNPs).
D-SNPs are a type of Medicare Advantage plan that offers extra coordination between your Medicare and Medicaid benefits. These plans may include:
- Enhanced care coordination
- Prescription drug coverage
- Extra services like dental, vision, hearing, or transportation
- Reduced or eliminated cost-sharing
Not all areas offer D-SNPs, and not everyone who is dual eligible will qualify for one, but if a plan is available in your county, it’s worth exploring.
How Medicare and Medicaid Work Together
When you’re enrolled in both programs, Medicare is the primary payer—meaning it pays first for covered services. Medicaid acts as the secondary payer, helping cover the costs Medicare doesn’t pay and adding additional services when applicable.
Here’s a basic example:
- You visit the doctor, and Medicare covers 80% of the bill.
- Medicaid may cover the remaining 20%, depending on your eligibility and state benefits.
- If you require long-term care or specialized home services, Medicaid may step in to cover those as well.
Applying for these programs requires working with both federal (for Medicare) and state (for Medicaid) agencies. Medicare enrollment usually happens automatically when you turn 65 or after 24 months of receiving disability benefits. Medicaid, however, requires a separate application through your state’s Medicaid office, and you’ll need to verify your income, assets, and health status.
Medicaid benefits also need to be renewed annually, and the process can require updated documentation. While Medicare does not require renewal, you should still review your coverage each year during the Medicare Open Enrollment Period.
Get Help Navigating Dual Eligibility
Managing both Medicare and Medicaid can be overwhelming, especially when eligibility rules and plan options vary by state. At Carolina Senior Benefits, we specialize in helping clients understand dual eligibility and make the most of their available benefits.
We can help you with:
- Applying for Medicaid
- Choosing a Medicare plan that works with Medicaid
- Understanding D-SNP options in your area
- Handling annual renewals and paperwork
Let us take the guesswork out of your healthcare coverage. If you or a loved one are eligible for both Medicare and Medicaid, contact Carolina Senior Benefits today. Our experienced advisors are here to walk you through every step of the process with clarity and compassion.
