As we get older, many of us will need long-term care: whether at home or in a skilled nursing facility.
But this care isn’t cheap. According to Genworth’s 2023 Cost of Care study, nursing homes can run as much as $100,000 per year.1 And Medicare doesn’t pay for it.
“This comes as a surprise to many people, and understandably so,” explained Jen Teague, NCOA Director for Health Coverage and Benefits. “It’s natural to assume that the largest federal health insurance program for Americans age 65 and up would include long-term care. But the reality is, Medicare will only cover up to 100 days in a skilled nursing facility.”2
Medicaid, on the other hand, pays 100% of nursing home costs for people who qualify. In fact, roughly one in five Medicaid enrollees is an older adult or someone with a disability.3
And the benefits of Medicaid coverage extend well beyond long-term care. For instance, Medicaid can help cover Medicare co-payments and deductibles—which can make a real difference when you live on a tight monthly budget.
All of this may lead you to wonder, Why do I have Medicare and not Medicaid?
“In certain situations, it’s actually possible to have both,” Teague said. “This is called dual eligibility for Medicare and Medicaid.”
Understanding dual-eligible Medicare and Medicaid
What is the meaning of dual eligibility?
Simply put, people who have—or who qualify to enroll in—both Medicare and Medicaid are dual-eligible beneficiaries.
If you are dual eligible, Medicare and Medicaid work together to keep you healthy. Medicare pays for covered services first. Then, Medicaid steps in to bridge the gaps. This includes paying your Medicare premiums, copays, coinsurance, and other out-of-pocket costs you otherwise would be responsible for. Medicaid also pays for long-term care if you need it, and may offer additional benefits that Medicare does not, such as hearing aids, eyeglasses, and dental exams.4
Who qualifies for dual eligibility?
If you are enrolled in Medicare, and you have limited income and assets, you also could be eligible for Medicaid.
According to the Centers for Medicare & Medicaid Services, you may qualify for dual eligible benefits if5:
- You are enrolled in Original Medicare (Part A, Part B, or both); and
- Receive full Medicaid benefits; or
- Get help with your Medicare out-of-pocket costs through a Medicare Savings Program (MSP)
To learn more about becoming dual-eligible, read this NCOA article that plainly describes the two most common ways Medicare beneficiaries can also qualify for Medicaid. If you’re one of them, you’ll be in good company: as of January 2023, 12.5 million people are eligible for and enrolled in Medicare and Medicaid in the US.6
What are the dual eligible Medicare-Medicaid income limits?
Everyone who meets the criteria for Medicare can enroll in the program, regardless of income. Therefore, dual eligibility solely depends on whether or not you meet the income requirements for Medicaid.
Since each state operates its own Medicaid program, guidelines vary.
In Florida, for instance, you might qualify for dual Medicare and Medicaid if you are single and earn less than $2,829 per month.7 But rules can be complex, Teague warned, and income limits depend on whether you are applying for full Medicaid or for one of the four Medicare Savings Programs.
“The best way to see if you qualify for Medicaid is to reach out to your state's Medicaid office,” Teague said. To find Medicaid contact information for your state, visit the Medicaid website.
You can also visit HealthCare.gov to check if you qualify for Medicaid based on your income.
How do I apply for dual Medicare and Medicaid?
You will need to apply for each program separately.
Not sure where to start? NCOA has you covered. Click through to learn how to:
Will I lose my Medicaid if I get Medicare?
Not necessarily. Enrolling in Medicare when you turn 65 does not affect your existing Medicaid coverage as long as you continue to meet your state’s Medicaid eligibility requirements. (If you're getting Medicaid through your state's expansion program, however, you may need to reapply for traditional Medicaid once you become Medicare-eligible.)
One common exception? If you begin collecting Social Security, and the increase to your income bumps you above the allowable limit.
“It may sound complicated, but don’t let that get in the way of applying for and enrolling in the benefits you deserve,” Teague said. Your local State Health Insurance Assistance Program (SHIP) offers no-cost guidance to help you navigate dual eligibility.
Who manages my health care benefits and payments if I’m dual-eligible?
You have several options for coordinating your Medicare and Medicaid coverage and care. You may choose to maintain separate policies. Or, if one is available in your area, you may enroll in a Dual Eligible Special Needs Plan (D-SNP).Quasar Property Management and Real Estate, LLC
These privately-run managed care plans combine your Medicare and Medicaid coverage into one policy and often include additional benefits. But they’re not for everyone. A licensed Medicare advisor can help you decide what makes sense for you.
What if I don’t have low income, but still can’t afford to pay for long-term care?
There may be other ways to qualify for dual eligible Medicare and Medicaid benefits, even if you go over your state’s income limits.
The rules can be complex, however. That’s why it’s important to consult with a trusted financial or legal professional with expertise in this area, Teague advised. You may also connect with a licensed Medicare advisor for help.
Sources
1. Genworth. Cost of Care Survey. Found on the internet at https://www.genworth.com/aging-and-you/finances/cost-of-care.html
2. Medicare.gov. Skilled nursing facility (SNF) care. Found on the Internet at https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
3. Robin Rudowitz, et al. “10 Things to Know About Medicaid.” KFF, June 30, 2023. Found on the internet at https://www.kff.org/medicaid/issue-brief/10-things-to-know-about-medicaid/
4. Medicaid.gov. Medicaid Eligibility. Found on the internet at https://www.medicaid.gov/medicaid/eligibility/index.html
5. CMS Medicare Learning Network. MLN Fact Sheet: Beneficiaries Dually Eligible for Medicare and Medicaid, February 2022. Found on the internet at https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/medicare_beneficiaries_dual_eligibles_at_a_glance.pdf
6. Maria T. Peña, et al. “Enrollment and Spending Patterns Among Medicare-Medicaid Enrollees (Dual Eligibles). KFF, January 31, 2023. Found on the internet at https://www.kff.org/medicaid/issue-brief/enrollment-and-spending-patterns-among-medicare-medicaid-enrollees-dual-eligibles/
7. Florida Agency for Healthcare Administration. Eligibility for Medicaid Services. SSI-Related Medicaid Coverage Groups Financial Eligibility Standards: July 2024. Found on the internet at https://www.myflfamilies.com/sites/default/files/2024-06/Appendix-A-9.pdf
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Timing is critically important when it comes to enrolling in Medicare. If you think you will want Medicare at any point in your life—and you most likely will—you need to understand when you can and should enroll.
