What "Dual Eligible" Means, and What Changes the Day It Describes You

The short answer, before anything else

"Dual eligible" means you have both Medicare and Medicaid at the same time.

That is the whole definition. Medicare's own wording is: "People who have both Medicare and full-benefit Medicaid coverage are 'dually eligible.'"

It is not a plan. It is not a product somebody sells you. It is a description of a situation — two programs covering one person, at once, on purpose. And the reason the phrase matters is that once it describes you, a set of rules switches on that do not apply to anybody else on Medicare.

Most people meet the term for the first time in a letter, which is a poor introduction. So here is what is actually behind it.

Why two programs at once is normal, not a mistake

People hear "you have both" and assume something has gone wrong, or that one will be taken away.

Neither. Medicare and Medicaid were built to do different jobs, and for a great many people both jobs need doing.

Medicare is the federal program you qualify for by age or by disability. It does not look at your income. It pays hospital and medical bills, and it has premiums, deductibles and coinsurance attached.

Medicaid is a joint federal and state program you qualify for based on income and, in some categories, on resources. In Colorado it is called Health First Colorado. It covers some things Medicare does not, and — the part almost nobody knows — it can pay Medicare's own costs on your behalf.

When both apply to the same person, Medicare goes first and Medicaid fills in behind it. Medicare's description of what the state does is plain: "Your state will pay your Medicare Part B (Medical Insurance) monthly premiums," and "your state might pay for: Your share of Medicare costs, like deductibles, coinsurance, and copayments."

That second sentence is worth reading twice. The deductible and the copay are the parts people actually feel.

What changes the day you are dual eligible

Four things switch on. They are the practical content of the term.

Your drug costs change automatically. Medicare states it directly: with both programs, "You'll automatically get Extra Help with your drug costs," and "You'll automatically be enrolled in a Medicare drug plan that will cover your drug costs instead of Medicaid." Extra Help is the federal subsidy for Part D, the prescription part of Medicare. You do not apply for it separately in this situation. It arrives with the status.

Medicaid may cover things Medicare will not. In Medicare's words, "Medicaid may pay for other drugs and services that Medicare doesn't cover." What that means in practice varies by state, which is why the honest version of this sentence is the hedged one.

You can change plans far more often than other people. Most people on Medicare get one annual window. People with Medicaid or Extra Help get a monthly opportunity instead — with real limits on where it can take you, which is its own subject.

There is a kind of plan built for exactly this. A Dual Eligible Special Needs Plan, usually written D-SNP, is a Medicare Advantage plan that CMS permits only for people who have both programs. We describe what CMS allows those plans to be built around on our dual eligible and Special Needs Plan page. Whether one exists that suits you, in your county, is a separate question and not one an article can answer.

The distinction that trips almost everybody

Notice that Medicare's definition says "full-benefit Medicaid coverage." That word full is doing a lot of work.

There is a second group of people who are not full-benefit dual eligible but who still get Medicaid paying part of their Medicare costs — through the Medicare Savings Programs, four programs run by each state that pay Medicare premiums and, in one case, cost sharing. People in that group are often described as partial dual eligible.

It matters because the two groups get different things, and because a person can easily qualify for one while assuming they qualify for neither. We have written the difference out properly in full-benefit and partial dual eligible, explained.

What it is not

It is not welfare in the sense people mean when they say it that way. Medicaid is a health coverage program. You paid into Medicare through your working life; this is the other half of a system that was designed with both halves.

It is not permanent, and it is not fragile either. Medicaid eligibility is reviewed. It can end if your circumstances change. But losing Medicaid does not take your Medicare plan away the same day — plans have a grace period, set by the plan, that runs at least thirty days and can run to six months. A great many websites print a flat six months. That is not what the rule says.

It is not something you have to be destitute for. The income limits for the Medicare Savings Programs are higher than most people assume, and Medicare's own guidance on them is unusually direct: "Even if you don't think you qualify, you should still apply," and "You may still qualify for these programs in your state even if your income or resources are higher than the federal limits listed."

We have seen people rule themselves out on a number they half-remembered. It is the single most common way this benefit goes unclaimed.

How to find out where you stand

Three separate questions, and they have three separate answers:

1. Do you have Medicaid? In Colorado that is Health First Colorado. If you are not sure, the Member Contact Center is 800-221-3943, State Relay 711.
2. Do you have a Medicare Savings Program? These are applied for through your state, not through Medicare.
3. Do you have Extra Help? That is Social Security's, and with full Medicaid you have it automatically.

A person can have one, two or all three, and the combinations are what decide what you actually pay. Working out which ones apply to you is most of the value of a proper review, and it is the first thing we do.

Where this comes from

Haven Health Plans was started by the pharmacists at Good Day Pharmacy, which operates a network of local community pharmacies across Colorado, Wyoming and Nebraska. The reason we write about this in detail is that the pharmacy counter is where the consequences show up — somebody paying full price for a prescription that a program they already qualify for would have covered.

We do not pick plans around pharmacies. A recommendation rests on your medication list, your doctors and your budget.

If a letter used the phrase "dual eligible" and you are not sure whether it describes you, that is a ten-minute conversation, and there is no charge for it.