What is Dual Eligibility for Medicare and Medicaid?

People who are eligible for and enrolled in both Medicare and Medicaid are called “dual eligibles” or “dually eligible beneficiaries.” Dual eligibles are a unique group of people, often with many health and social support needs. In 2013, Hawaii had 39,400 people who qualified.


Many people get confused about the differences between Medicare and Medicaid so let’s start with a brief explanation. Both programs offer access to health care services, Medicare is a federal health insurance program for seniors and disabled persons while Medicaid is a state and federal medical assistance program to support people with financial need of all ages. The Centers for Medicare and Medicaid Services (CMS) runs both programs but the Medicaid program is run through state agencies while Medicare is run through the Social Security Administration (SSA).

One of the main benefits differences is that Medicaid provides long-term nursing home care, both in home and in community-based settings. It is important to note that in 2019, Medicare Advantage Plans (Part C) started including some long-term home and community-based benefits.


If you are eligible for Medicaid and will be transitioning to Medicare soon, contact a Medicare agent who can show you your options and help you find the right plan for your needs.


Who qualifies for dual eligibility?


In order to be “dually eligible”, a person must be enrolled in Medicare Part A (hospital insurance) and/or Medicare Part B (medical insurance) or a Medicare Advantage Plan (which always includes Medicare Part A and Medicare Part B). In addition, a person must be enrolled in either full coverage Medicaid or one of Medicaid’s Medicare Savings Programs (MSPs) that helps with the cost of Medicare.


What are the benefits of dual eligibility?

There are two potential main benefits to people who are eligible for both Medicare and Medicaid. They are:


1. More healthcare coverage

2. Lower out-of-pocket costs


Which program is the primary payer?

When a person has dual health insurance, there is a “primary payer” who is billed first and a “secondary payer” who is billed second. The idea is that the secondary payer picks up some or all of the bill that the primary payer doesn’t pay.


In the case of Medicare-Medicaid dual enrollees, Medicare is always the primary payer for Medicare covered expenses such as medical care and hospitalization. When Medicare fails to cover the full cost of service, Medicaid steps in as the secondary payer to cover the remaining cost as long as the bill is for Medicaid covered expenses. Medicaid is billed exclusively for expenses not covered by Original Medicare such as in-home personal care assistance.


Looking ahead


Many payer experts predict that Medicare Advantage Plan administrators will make it a priority to improve member experience for dual eligible beneficiaries. Because dual eligibles are enrolled in two plans – one run by the state and one run by the federal government there is an opportunity to integrate the two programs together so members have a more seamless experience. The end goal is to better coordinate member care in order to reduce costs and improve quality of care.

Contact a PBC Agent for Help


Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.


At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.