Who Qualifies for Dual Eligible Enrollment?

Who Qualifies for Dual Eligible Enrollment

If you qualify for both Medicare and Medicaid, you also qualify for a variety of benefits, like assistance paying your Medicare costs.

Medicare is federal health insurance for people aged 65 and older, some younger people with disabilities, or those with end-stage renal disease (ESRD). Part A provides hospital insurance, and Part B provides medical insurance.

Medicaid is a federal and state program that provides health insurance coverage to people with low income and resources. Medicaid also offers coverage for some healthcare services not normally covered by Medicare. Each state operates its own Medicaid program within federal guidelines, offering different benefits and having varying eligibility requirements.

In some cases, individuals may be eligible for both Medicare and Medicaid. This is called dual eligibility. Read on to learn more about what being dual eligible means and when you can enroll in a dual-eligible plan.

What does being dual eligible mean?

Dual eligibility, or being dual eligible, means you qualify for both Medicare and Medicaid. You may be enrolled in Medicare first and then qualify for Medicaid, or vice versa.

Dual eligible beneficiaries are:

  • Enrolled in Medicare Part A and/or Part B and
  • Are enrolled in full-benefit Medicaid and/or the Medicare Savings Programs (MSPs) administered by each individual state

There are several categories dual eligible individuals can fall in, each providing varying cost-sharing or benefit coverage by both Medicare and Medicaid.

Mallori Hyland, Licensed Sales Agent with ClearMatch Medicare

What are Medicare Savings Programs?

MSPs are federally funded programs that help beneficiaries pay for out-of-pocket Medicare costs. Each state has different types of programs available with varying income and asset limit requirements, but the primary types of Medicare-Medicaid plans available are:

  • Qualified Medicare Beneficiary (QMB) program
  • Specified Low-Income Medicare Beneficiary (SLMB) program
  • Qualifying Individual (QI) program
  • Qualified Disabled and Working Individuals (QDWI) program

Each of these programs has partial or full benefits available, which determines:

  • How much of Medicare premiums and cost-sharing is paid for by Medicaid
  • How much Medicaid coverage the enrollee receives

In some cases, someone may qualify for more than one program, and they can choose which to apply to, or they can apply to more than one.

Learn more: How to Qualify for a Medicare Savings Program

What is Medicare Extra Help?

Extra Help is a Medicare program designed to help people with limited income and resources pay for Part D prescription drug coverage, including:

  • Premiums
  • Deductibles
  • Coinsurance
  • Other costs

You automatically qualify for Extra Help if you get full Medicaid benefits, help from an MSP, or Supplemental Security Income (SSI) benefits from Social Security. You can also apply for Extra Help if you don’t automatically qualify.

What are Medicare Special Needs Plans?

Special Needs Plans (SNPs) are a type of Medicare Advantage plan, but membership is limited to people with specific diseases or characteristics. The plans are tailored to these enrollees to meet their unique needs, including:

  • Benefits
  • Provider options
  • Drug formularies

Typically, SNPs cover specialists in the diseases or conditions that affect their members. Some require you to have a primary care doctor who helps coordinate your care, and some also require referrals to see a specialist.

Those who are eligible for SNPs include people who:

  • Are dual eligible (D-SNP)
  • Live in certain institutions, like a nursing home
  • Have specific chronic or disabling conditions, such as diabetes, ESRD, chronic heart failure, or dementia

Some plans may limit their membership to one specific condition or a group of related conditions. To learn if you’re eligible for an SNP, you can call us toll-free at 888-992-0738 and speak to one of our licensed Medicare agents. They’ll answer your questions in plain English and explain your Medicare options.

When can you enroll in a dual health plan if you have Medicaid and Medicare?

You can apply for an MSP at any time, though applying at the time of your initial enrollment period (IEP) may be the best option because you will receive the savings benefits as soon as your coverage begins.

Your IEP is when you first become eligible for Medicare. It lasts for seven months, starting three months before you turn 65 and ending three months later.

You can also enroll in an SNP at any time as long as you qualify for coverage.

Special enrollment periods if you get Extra Help

In some cases, you may qualify for a Special Enrollment Period when you can join, switch, or drop your Medicare Advantage (Part C) plan or Medicare prescription drug coverage. From January through March, April through June, and July through September:

  • If you are eligible for both Medicare and Medicaid, you can join, switch, or drop your MA or Part D plan one time during an SEP. The change will take effect on the first day of the following month.
  • If you qualify for Extra Help paying for Medicare drug coverage, you can also join, switch, or drop Part D coverage one time. The change will begin on the first day of the following month.

Compare Dual Eligible Special Needs Plans now

Additionally, if you’re enrolled in a State Pharmaceutical Assistance Program (SPAP) or lose SPAP eligibility, you can join a Part D or MA plan (with prescription drug coverage) once during the calendar year.

Can I lose dual eligibility?

It’s possible to lose dual eligibility if you stop meeting the criteria for Medicaid, such as if you have a change in income levels, family size, or other reasons.

If you’re enrolled in a D-SNP plan but lose Medicaid coverage, you may no longer meet the plan’s requirements. Depending on your plan, you will enter a grace period ranging from 30 days to six months to regain eligibility. If you do not regain eligibility during this time, you’ll be disenrolled from the SNP.

If a Medicaid enrollee loses coverage and is disenrolled from their SNP or MSP plan, they will have a special enrollment period to enroll in either a Medicare Advantage plan or Original Medicare and a Part D plan (starting the month you no longer qualify for your previous plan).

Additional resources

After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how overwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.


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