Dual Eligible Guide for Seniors – How to Get Both Medicare and Medicaid
2025 Dual Eligible Guide: Income Limits, Benefits & How to Apply (Save $6,000+ Annually)
Last updated: August 17, 2025 Reviewed by: Sarah Martinez, Certified Benefits Counselor, and the Grants for Seniors Research Team
⚠️ If You Need Emergency Help
Don’t wait to get help if you’re having trouble with your Medicare or Medicaid benefits:
- For Medicare issues: Call Medicare directly at 1-800-MEDICARE (1-800-633-4227), available 24/7
- For Medicaid issues: Contact your state Medicaid office (find yours at Medicaid.gov/state-overviews)
- For help applying for benefits: Call your local State Health Insurance Assistance Program (SHIP) at 1-877-839-2675
- For food assistance: Call 211 to find local food banks and meal programs
- For housing help: Contact your local Area Agency on Aging at 1-800-677-1116
Key Takeaways
Bottom Line: If you qualify for both Medicare and Medicaid, you can get much better health coverage at little to no cost. About 12.8 million Americans are “dual eligible,” and this could save you thousands of dollars per year.
What You Get:
- All your Medicare premiums, deductibles, and copays covered
- Extra prescription drug help (pay only up to $4.90 for generics, $12.15 for brand-name drugs in 2025)
- Long-term care that Medicare doesn’t cover
- Transportation to medical appointments
- Special Medicare plans designed just for dual eligibles
2025 Income Limits (Most States):
- Single person: Up to $1,275/month for full benefits (Federal Poverty Guidelines 2025)
- Married couple: Up to $1,717/month for full benefits
- Higher income limits available for partial benefits (up to $1,781 single/$2,400 couple)
What Does “Dual Eligible” Mean?
Being “dual eligible” simply means you qualify for both Medicare and Medicaid at the same time. You’re not choosing one or the other – you get both programs working together to cover your health care costs.
Here’s how it works:
- Medicare pays first for covered services (like doctor visits and hospital stays)
- Medicaid picks up what Medicare doesn’t cover, including copays, deductibles, and services Medicare doesn’t provide
According to CMS data from 2025, this dual coverage serves 7.2 million low-income seniors plus 5.6 million people with disabilities who are also on Medicare.
Real Example: Maria, 67, from Phoenix, was paying $185/month for Medicare Part B plus $400/month for prescriptions. After qualifying as dual eligible, she now pays $0 for Part B and just $4.90 per prescription – saving her over $6,500 annually.
Who Qualifies?
You can be dual eligible if you meet requirements for both programs:
Medicare Requirements:
- Age 65 or older, OR
- Under 65 with certain disabilities, OR
- End-stage kidney disease, OR
- ALS (Lou Gehrig’s disease)
Medicaid Requirements:
- Low income (see income tables below)
- Limited assets
- U.S. citizen or qualified immigrant
- Resident of the state where you’re applying
Types of Dual Eligible Coverage
Not everyone gets the same level of dual eligible benefits. There are two main types:
Full Dual Eligible Benefits
You get complete Medicaid coverage plus Medicare. This means:
- Medicaid pays all your Medicare premiums, deductibles, and copays
- You get all Medicaid services like nursing home care, home health aides, and transportation
- You pay almost nothing out-of-pocket for health care
Partial Dual Eligible Benefits (Medicare Savings Programs)
You get help with Medicare costs but not full Medicaid. There are four programs:
1. Qualified Medicare Beneficiary (QMB)
What it covers: All Medicare premiums, deductibles, and copays 2025 Income Limits (Federal Register, January 2025):
- Single: $1,275/month ($15,300/year)
- Couple: $1,717/month ($20,604/year) Asset Limits: $9,430 (single), $14,130 (couple)
2. Specified Low-Income Medicare Beneficiary (SLMB)
What it covers: Medicare Part B premium only 2025 Income Limits:
- Single: $1,530/month ($18,360/year)
- Couple: $2,060/month ($24,720/year) Asset Limits: $9,430 (single), $14,130 (couple)
3. Qualifying Individual (QI)
What it covers: Medicare Part B premium only 2025 Income Limits:
- Single: $1,721/month ($20,652/year)
- Couple: $2,318/month ($27,816/year) Asset Limits: $9,430 (single), $14,130 (couple) Important: Limited funding – apply early each year, first-come first-served
4. Qualified Disabled Working Individual (QDWI)
What it covers: Medicare Part A premium for people with disabilities who returned to work Requirements: Must be under 65, disabled, working, and lost free Medicare Part A due to work income
2025 Income and Asset Limits
| Program | Single Monthly Income | Couple Monthly Income | Asset Limit (Single) | Asset Limit (Couple) |
|---|---|---|---|---|
| QMB | $1,275 | $1,717 | $9,430 | $14,130 |
| SLMB | $1,530 | $2,060 | $9,430 | $14,130 |
| QI | $1,721 | $2,318 | $9,430 | $14,130 |
| Full Medicaid | Varies by state* | Varies by state* | $2,000* | $3,000* |
*Full Medicaid limits vary significantly by state. Contact your state Medicaid office for exact amounts.
Reality Check: Some states have no asset limits or higher income limits. Twelve states currently have no asset limits for Medicare Savings Programs: Alabama, Arizona, Connecticut, Delaware, Louisiana, Maine, Mississippi, New Mexico, New York, Oregon, Vermont, and Washington D.C.
Important Warning About Estate Recovery: Federal law requires states to recover costs from estates of Medicaid beneficiaries for long-term care services received after age 55. This doesn’t affect Medicare Savings Programs (QMB, SLMB, QI) but does apply to full Medicaid benefits.
What Assets Don’t Count
When determining if you qualify, these assets are typically NOT counted:
- Your home (primary residence)
- One car
- Personal belongings and household items
- Burial plots and up to $1,500 in burial funds
- Life insurance with face value under $1,500
- Property needed for work or business
Warning: The asset limits are strict for most programs. If you’re close to the limit, consider speaking with a benefits counselor about legal ways to reduce countable assets.
Extra Help with Prescription Drugs
All dual eligible individuals automatically qualify for “Extra Help” with Medicare Part D prescription drug costs. In 2025, this means:
What You Pay for Prescriptions
- Generic drugs: $0-$4.90 per prescription (CMS Part D Coverage 2025)
- Brand-name drugs: $0-$12.15 per prescription
- No coverage gap (donut hole)
- No late enrollment penalties
Estimated Annual Savings
The Social Security Administration estimates this Extra Help benefit averages $5,900 per year for people who take multiple medications.
Medicare Advantage Plans for Dual Eligibles
If you’re dual eligible, you have access to special Medicare Advantage plans called Dual Eligible Special Needs Plans (D-SNPs). These plans:
- Combine your Medicare and Medicaid benefits into one plan
- Often have $0 monthly premiums
- Include prescription drug coverage
- Offer extra benefits like transportation, food allowances, and home modifications
- Coordinate your care between Medicare and Medicaid services
Types of D-SNPs
| Plan Type | What It Means | Level of Integration |
|---|---|---|
| FIDE-SNP | Fully Integrated Dual Eligible SNP | Highest – one plan for all Medicare and Medicaid services |
| HIDE-SNP | Highly Integrated Dual Eligible SNP | High – same company manages both programs |
| Coordination-Only | Basic D-SNP | Lower – coordinates between separate Medicare and Medicaid plans |
Reality Check: Not all areas have D-SNPs available. Rural areas especially may have limited options. You can keep Original Medicare if you prefer, but D-SNPs often provide better coordination and extra benefits.
Long-Term Care Benefits
This is where being dual eligible really shines. Medicare only covers skilled nursing care for up to 100 days and only when you’re recovering from a hospital stay. Medicaid covers:
- Nursing home care indefinitely
- Home health aides for daily activities
- Adult day care programs
- Assisted living (in many states)
- Home modifications for safety and accessibility
Home and Community-Based Services (HCBS)
Most states offer HCBS waivers that let you get long-term care at home instead of a nursing home. Services can include:
- Personal care assistance
- Meal delivery
- Transportation
- Home modifications (ramps, grab bars)
- Adult day programs
- Respite care for family caregivers
Tip: There are often waiting lists for HCBS services. Apply as soon as you think you might need help, even if it’s not immediate.
Special Considerations for Different Groups
Veteran Seniors
If you’re a veteran, you have unique options:
- VA benefits can work alongside Medicare and Medicaid
- CHAMPVA may provide additional coverage for family members
- VA nursing homes may accept Medicaid payments
- Service-connected disabilities can qualify you for additional VA benefits regardless of income
Veterans with 100% disability ratings get comprehensive VA healthcare that coordinates with Medicare/Medicaid.
Contact: Call the VA at 1-800-827-1000 for help coordinating benefits.
Expert Insight: “Veterans often don’t realize they can use VA healthcare alongside Medicare and Medicaid,” says Dr. Michael Torres, VA Benefits Counselor. “The coordination can provide comprehensive coverage with minimal out-of-pocket costs, especially for service-connected conditions.”
LGBTQ+ Seniors
LGBTQ+ older adults face unique challenges but have the same rights to Medicare and Medicaid services:
- Non-discrimination protections apply to all Medicare and Medicaid funded services
- Medicaid long-term care cannot discriminate based on sexual orientation or gender identity
- Same-sex spouses have the same Medicare and Medicaid rights as opposite-sex couples
- Gender-affirming care may be covered by Medicaid in many states
Over 1.2 million LGBTQ+ older adults rely on Medicaid for healthcare access.
Resources:
- SAGE National LGBT Elder Hotline: 1-877-360-LGBT
- Justice in Aging LGBTQ+ Resources
Community Voice: “Finding affirming healthcare as an older transgender woman was challenging until I learned about my rights under Medicaid,” shares Linda K., 72, from San Francisco. “Now my gender-affirming care is covered, and I have access to culturally competent providers.”
Native American and Alaska Native Seniors
American Indian and Alaska Native (AI/AN) dual eligibles have special protections:
- No cost-sharing for services received at Indian Health Service, Tribal, or Urban Indian health facilities
- No Medicaid premiums or enrollment fees if eligible for I/T/U services
- 100% federal match for Medicaid services at I/T/U facilities
- Special enrollment rights for Marketplace plans year-round
Contact: Find your local tribal health program or call the Indian Health Service at 1-301-443-3593.
Disabled Seniors
If you became eligible for Medicare due to disability:
- You may have Medicare before age 65
- SSDI benefits often continue alongside Medicare
- Work incentives allow you to try working while keeping benefits
- Ticket to Work program provides vocational rehabilitation services
Tip: People with disabilities under 65 who are dual eligible often face unique challenges accessing care, especially in rural areas and for mental health services.
Rural Seniors
Rural dual eligibles face specific challenges:
- Provider shortages especially for specialists and mental health
- Transportation barriers to medical appointments
- Limited D-SNP options or no plans available
- Longer travel distances for care
Solutions:
- Medicaid transportation is required in all states for medical appointments
- Telehealth services expanded under Medicare and Medicaid
- Rural Health Clinics often accept both Medicare and Medicaid
- Area Agencies on Aging provide local transportation programs
Contact: National Aging and Disability Transportation Center at 1-866-983-3222 for local transportation resources.
Rural Reality: “Living 45 minutes from the nearest doctor meant I was skipping appointments,” explains Robert M., 68, from rural Montana. “Once I learned about Medicaid transportation and telehealth options through my D-SNP, I haven’t missed an appointment in two years.”
Transportation Benefits
Getting to medical appointments is often a major challenge for seniors. Here’s what’s available:
Medicaid Transportation
All states must provide transportation to Medicaid appointments, including:
- Medical and dental appointments
- Mental health services
- Pharmacy visits
- Medicaid-covered services
Reality Check: The type of transportation varies by state – it might be a medical van, taxi, bus vouchers, or mileage reimbursement.
Medicare Advantage Transportation
Many D-SNPs and other Medicare Advantage plans now offer:
- Rides to/from medical appointments
- Grocery store trips
- Pharmacy visits
- Some social activities
Other Transportation Options
- Area Agencies on Aging: Call 1-800-677-1116
- 211: Dial 2-1-1 for local transportation resources
- Religious organizations and community groups
- Senior center transportation programs
How to Apply
For Medicare Savings Programs (QMB, SLMB, QI)
- Contact your state Medicaid office (each state runs these programs differently)
- Apply at your local Social Services office
- Online applications available in most states
- Required documents:
- Social Security card
- Medicare card
- Proof of income (Social Security statements, pay stubs)
- Bank statements
- Proof of address
For Full Medicaid
- Apply through your state Medicaid office
- Healthcare.gov for some states
- Local Social Services departments
- Hospital financial counselors can often help with applications
Tip: Don’t assume you won’t qualify. Income and asset limits vary by state, and many people who think they earn “too much” actually qualify for help.
Common Problems and Solutions
Problem: Providers Don’t Accept Your Coverage
Solution:
- Make sure providers understand you have both Medicare and Medicaid
- Show both cards at every appointment
- QMB beneficiaries cannot be balance billed – report violations to Medicare
Problem: Medicaid Renewal Delays
Solution:
- Submit renewals early
- Keep copies of all paperwork
- Contact your state Medicaid office if benefits are interrupted
- Know your rights – you can appeal coverage decisions
Problem: Prescription Drug Coverage Gaps
Solution:
- Understand that Medicare handles your prescription coverage, not Medicaid
- Use Medicare Plan Finder to compare drug plans
- Ask about generic alternatives
- Look into manufacturer assistance programs
Problem: Long Wait Times for Services
Solution:
- Apply for HCBS services early, even if you don’t need them immediately
- Ask about emergency or urgent priority categories
- Consider private pay options while waiting for Medicaid approval
Money-Saving Tips
Prescription Drugs
- Always use generic versions when available
- Mail-order pharmacies often cost less
- Manufacturer patient assistance programs for expensive drugs
- GoodRx and similar programs may be cheaper than your copay for some drugs
Medical Equipment
- Rent vs. buy – Medicaid often prefers rental for wheelchairs, hospital beds
- Prior authorization – get approval before ordering expensive equipment
- Multiple quotes – shop around for approved suppliers
Dental Care
- Medicaid dental coverage varies dramatically by state
- Community health centers often provide sliding-scale dental care
- Dental schools offer low-cost care by students under supervision
Frequently Asked Questions (FAQs)
Q: If I have both Medicare and Medicaid, which one pays first?
A: Medicare always pays first for services it covers. Medicaid then pays Medicare’s deductibles, copays, and services Medicare doesn’t cover.
Q: Will having Medicaid affect my Medicare benefits?
A: No, Medicaid enhances your Medicare benefits. You keep all Medicare services and gain additional coverage through Medicaid.
Q: Can I lose my dual eligible status?
A: Yes, if your income increases or you gain assets above the limits. However, you can reapply if your situation changes again. Some states have “spend-down” programs that let you qualify by paying medical expenses to reduce your countable income.
Q: What happens to my benefits when I die? Will my family lose our home?
A: Medicare Savings Programs (QMB, SLMB, QI) have no estate recovery. Full Medicaid may pursue estate recovery for long-term care costs paid after age 55, but your home is generally protected if a spouse, disabled child, or child under 21 lives there. State rules vary significantly.
Q: Do I need to choose between Original Medicare and Medicare Advantage if I’m dual eligible?
A: You can choose either. Medicare Advantage D-SNPs offer coordinated care, but Original Medicare gives you more provider choice.
Q: What if my state didn’t expand Medicaid?
A: You can still qualify for Medicare Savings Programs (QMB, SLMB, QI) which help with Medicare costs, even in non-expansion states.
Q: Can I have both Medicaid and private insurance?
A: Yes, but Medicaid typically pays last after Medicare and any other insurance.
Q: How often do I need to reapply for benefits?
A: Most states require annual renewal for Medicaid benefits. Medicare Savings Programs also require yearly applications.
Q: What if I disagree with a coverage decision?
A: You have appeal rights for both Medicare and Medicaid decisions. Contact the program that denied coverage for specific appeal procedures.
Q: Can Medicaid help pay for my spouse’s Medicare costs?
A: Medicaid can only help with Medicare costs for the person who qualifies. However, spousal income rules may allow one spouse to qualify while the other doesn’t.
Q: What happens to my benefits if I move to another state?
A: You’ll need to reapply in your new state. Benefits and eligibility rules vary by state.
Program Details
Program of All-Inclusive Care for the Elderly (PACE)
What it is: PACE provides comprehensive medical and social services for people 55+ who need nursing home-level care but want to live at home.
What it covers:
- All Medicare and Medicaid services
- Transportation to PACE centers
- Adult day care
- Home care services
- Prescription drugs
- Medical equipment
How it works: You get all your care through a PACE center. A team of doctors, nurses, social workers, and therapists coordinate everything.
Cost: If you’re dual eligible, you typically pay nothing for PACE services.
Availability: PACE programs exist in 31 states but aren’t available everywhere.
Medicaid Buy-In Programs
Some states allow people with higher incomes to “buy in” to Medicaid by paying a monthly premium. This can be valuable if:
- Your income is slightly above Medicaid limits
- You need Medicaid’s long-term care services
- You want Medicaid’s comprehensive coverage
State Pharmaceutical Assistance Programs (SPAPs)
Several states offer additional prescription drug help beyond Medicare Extra Help:
- Pennsylvania: PACE and PACENET programs
- New Jersey: Pharmaceutical Assistance to the Aged and Disabled
- Delaware: Prescription Assistance Program
- States with SPAPs often provide: Lower copays, coverage during the donut hole, help with Medicare Part D premiums
Resources by Region
National Resources
- Medicare: 1-800-MEDICARE (1-800-633-4227) | Medicare.gov
- Medicaid: Medicaid.gov/state-overviews
- SHIP (State Health Insurance Assistance Program): 1-877-839-2675 | ShipHelp.org
- Area Agencies on Aging: 1-800-677-1116 | Eldercare Locator
- Benefits CheckUp: BenefitsCheckUp.org – Find all benefits you might qualify for
State-Specific Help
Each state runs Medicaid differently. Contact your state’s specific agencies:
Find your state Medicaid office: Medicaid.gov/state-overviews
State Health Insurance Assistance Programs (SHIP): Every state has free, unbiased Medicare counseling. Find yours at ShipHelp.org
Legal Help
- National Center on Law and Elder Rights: NCLER.acl.gov
- Justice in Aging: JusticeInAging.org
- Center for Medicare Advocacy: MedicareAdvocacy.org
About This Guide
Researched and Compiled by Grants for Seniors
This guide has been carefully researched using publicly available government resources and official program websites. We systematically review federal and state program information to create comprehensive, accurate guides for older Americans seeking grant opportunities.
Our Sources: All information comes from official sources including federal agency websites (HHS, USDA, SSA, CMS), state government departments, official program documentation, and verified nonprofit organization resources.
Verification Process: Each program listing undergoes thorough online verification by cross-referencing information across multiple official sources, checking current program status, verifying contact information, and confirming eligibility requirements and deadlines.
Information Currency:
- Last Updated: August 2025
- Sources Verified: August 2025
- Next Review: February 2026
Important Note: Government programs can change without advance notice. While this guide uses the most current available information, we strongly recommend verifying all details directly with program administrators before applying.
Found an Error? If you discover outdated information or additional programs that should be included, please contact us at info@grantsforseniors.org.
Disclaimer: This guide is for informational purposes only and does not constitute professional advice. Always confirm program details with official sources before applying. Program details can change, and readers should always verify information with the relevant agency.
This resource is independently researched to help seniors access available financial assistance programs.