Navigating the Complexity of Medicaid and Medicare Dual Eligibility

doctor and patientQ. I am aware that many people are eligible for both Medicaid and Medicare. How does dual eligibility work? It seems like anything involving Medicaid and/or Medicare can be pretty complicated. Can you tell me more about it and if/how these two programs are somehow integrated? Thanks for your help!

A. Please note that this article deals primarily with Medicaid health coverage, which is a completely different type of coverage from the Medicaid long-term care coverage that I, as a Medicaid asset protection attorney, typically write about and talk about. Currently, 12.5 million people qualify for both Medicaid health coverage and Medicare health coverage, making dual eligibility quite common in the U.S. If you’re someone with dual eligibility, your Medicare and Medicaid health coverage plan(s) work together to provide health coverage for your needs. Most dual eligible enrollees are eligible for the full range of Medicaid health benefits not otherwise covered by Medicare.

Dual eligible enrollees include people ages 65 and over who are in relatively good health but who may have limited financial resources. Some enrollees may have had more financial resources at one time, but spent their income and wealth on health or long-term care costs. Dual enrollees can also include people with lifelong intellectual and developmental disabilities who have always faced employment challenges and people under the age of 65 who may have left the labor force due to significant physical or mental impairments.

How Does Dual Enrollment Work?

Medicaid is jointly funded by states and the federal government. The federal government matches state spending for eligible beneficiaries and qualified services without a limit. The federal share of spending for most Medicaid enrollees is determined by a formula. Most full-benefit Medicare-Medicaid enrollees are also eligible for Medicare premium and cost-sharing assistance covered under the Medicare Savings Programs, which are both administered by the states. Those who are partial benefit Medicare-Medicaid enrollees are not eligible for full Medicaid benefits, but are eligible for assistance with Medicare premiums and, in many cases, cost sharing through a Medicare Savings Program.

For those who are dual eligible, in most cases, Medicare is the primary plan and covers most Medicare-eligible healthcare services; Medicaid is typically the secondary plan and may cover medical costs that Medicare doesn’t fully cover. To be eligible for full Medicaid benefits, Medicare beneficiaries must meet states’ Medicaid eligibility criteria. To qualify for dual eligibility, you must meet the requirements for both Medicare and Medicaid and be enrolled in both programs.

Being dual eligible obviously can provide greater healthcare coverage for those who qualify. This is because Medicaid covers some expenses that Medicare does not. However, navigating the complexity of either Medicare or Medicaid is challenging. Those challenges are compounded for people enrolled in both programs. A recent study aims to make integration of the programs less complicated.

Study Indicates Positive Outcomes for New Approach to Medicare/Medicaid Dual Enrollment

A team of researchers from William & Mary, Virginia Commonwealth University, and the Virginia Department of Medical Assistance Services studied the potential benefits of integrating care for dually enrolled Medicare and Medicaid members. The study was a collaborative effort across these Virginia universities and agencies and was funded by Virginia Medicaid. Some of their findings, published in June 2024 in JAMA Health Forum, are as follows:

  • Those enrolled in both Medicare and Medicaid often face financial insecurity, complex health conditions, and high rates of disability. This has led to a focus on how to integrate the programs to improve experiences and outcomes for dually enrolled members.
  • Integration can reduce expenses for the state and federal agencies funding the programs by sharing member information and customer service systems between the two programs and, potentially, coordinating the care the member receives from each program.

How Do Highly Integrated Dual Eligible Special Needs Plans (D-SNPs) Work in Virginia?

One way to integrate the Medicare/Medicaid programs is through a Dual Eligible Special Needs Plan, a type of private Medicare Advantage plan. In 2022, Virginia was one of only nine states where Medicaid members had the option to enroll in a Dual Eligible Special Needs Plan. DC and Maryland were not among the states with this option. In 2020-2021, several private insurers in Virginia decided to create more highly integrated Dual Eligible Special Needs Plan. This change created a unique opportunity to study the experiences that members have when they are in these integrated plans. The hope was that the results of this change in Virginia would inform other states’ decisions to incorporate these highly integrated plans in their Medicaid programs.

The research team found that being in Dual Eligible Special Needs Plan was associated with greater satisfaction with customer service. They found that:

  • A better process occurs when the private insurer delivering a member’s Medicare benefits is the same private insurer delivering the member’s Medicaid benefits and Dual Eligible Special Needs Plans include only members whose coverage is aligned in this way.
  • The alternative, where enrolled members are in different private insurance plans for their Medicare and Medicaid benefits, or in traditional Medicare and a private plan for Medicaid, can lead to confusion for the enrolled member and higher costs for the government.

When participating in a Dual Eligible Special Needs Plan, “(m)embers knew who to call if they had issues with getting access to a certain type of care. They were more likely to report being treated with courtesy and respect,” study lead Jennifer M. Mellor, PhD, said. “When you have multiple plans, knowing who to call and getting a resolution to that call can be challenging and frustrating. And we did see improvement in that.” Mellor would like to see what experiences members have after being enrolled for a longer period of time (study participants were only enrolled for 6 months.)

For more details about Dual Eligible Special Needs Plans in Virginia, visit the Department of Medical Assistance Services – Virginia Medicaid page. For more details about Medicare and Medicare Advantage plans, please read my many articles on this subject.

Medicaid Laws are the Most Complex and Confusing Laws in Existence

Medicaid laws are generally impossible to understand without highly experienced legal assistance. Remember that this article deals with Medicaid health coverage, as opposed to Medicaid long-term care coverage that I typically write about. The rules for these two different programs are completely different, and the fact that they are both called Medicaid makes it incredibly confusing for everybody. Earlier this month I wrote an article titled, “Misinformation about Medicaid in Popular Media and Journalists Getting Legal Information from Non-Lawyers.” Since most people get their Medicaid information from the popular media, it is no wonder that so many consumers are confused about what Medicaid is and how it works.

Despite today’s educational article being about health insurance Medicaid, almost all of the Medicaid asset protection work that the Farr Law Firm does deals with getting people eligible for long-term care Medicaid, the type of Medicaid that pays for nursing home level care, whether that takes place in a nursing home, or at home, or sometimes in an assisted living facility. Without proper Medicaid asset protection planning for Medicaid long-term care benefits, and legal advice from an experienced Elder Law Attorney, such as myself, who understands the incredibly complex rules surrounding Medicaid long-term care benefits, many people spend much more than they should paying for long-term care and often going broke in the process, unnecessarily jeopardizing their future care and well-being, as well as the financial and emotional security of their family. Please read the Medicaid Complexity page on our website for more details.

It is extremely prudent to legally protect your assets in an effort to qualify for Medicaid long-term care benefits when needed, and to do so with the help of a highly experienced Elder Law Attorney. Don’t ever hide your assets (hide is quite literally a dirty four-letter word), and don’t make the mistake of attempting to protect your assets on your own. Make the wise choice, and call an experienced Certified Elder Law Attorney, such as myself, when you are ready.

Medicaid Asset Protection Fairfax: 703-691-1888
Medicaid Planning Fredericksburg: 540-479-1435
Elder Law Rockville: 301-519-8041
Elder Care DC: 202-587-2797

Print This Page
About Evan H Farr, CELA, CAP

Evan H. Farr is a 4-time Best-Selling author in the field of Elder Law and Estate Planning. In addition to being one of approximately 500 Certified Elder Law Attorneys in the Country, Evan is one of approximately 100 members of the Council of Advanced Practitioners of the National Academy of Elder Law Attorneys and is a Charter Member of the Academy of Special Needs Planners.