Dual Eligibility: When You Have Both Medicare and Medicaid, Who Pays What

People who have both Medicare and full Medicaid coverage are called "dually eligible." Medicare pays first for Medicare-covered services, and Medicaid may pay after that, including Medicare costs like deductibles and coinsurance. You automatically get Extra Help with drug costs, and your prescriptions are covered by Medicare drug coverage. If you're in the Qualified Medicare Beneficiary (QMB) program, Medicare providers aren't allowed to bill you for Medicare deductibles, coinsurance, or copays for covered services.

What does "dual eligible" mean?

Medicare.gov uses "dually eligible" for people who have Medicare and full-benefit Medicaid coverage. Medicaid is a joint federal and state program, so rules and benefits vary by state.

Some people don't have full Medicaid but get help from a Medicare Savings Program, which is run by state Medicaid offices. These programs help pay Medicare premiums and, for QMB members, deductibles and coinsurance.

Who pays first?

Medicare.gov says Medicare pays first when you're dually eligible and get Medicare-covered services. Medicaid pays after Medicare and may cover:

• Medicare costs you would otherwise owe, like deductibles and coinsurance, depending on your state and your Medicaid category.
• Services Medicare doesn't cover, such as long-term nursing home care, and in some states other benefits.

Medicaid is usually the payer of last resort. That means other coverage pays before it.

How does drug coverage work?

Medicare.gov says if you're dually eligible:

• Medicare covers your prescription drugs, not Medicaid.
• You'll automatically get Extra Help with your drug costs.
• You'll automatically be enrolled in a Medicare drug plan if you don't choose one yourself.

Extra Help lowers what you pay for drug premiums, deductibles, and copays.

Can a provider bill me if I'm in QMB?

The Qualified Medicare Beneficiary (QMB) program helps pay Part A and Part B premiums, deductibles, coinsurance, and copays. Medicare.gov is clear: if you qualify for QMB, Medicare providers aren't allowed to bill you for services and items Medicare covers, including deductibles, coinsurance, and copayments.

Medicare.gov suggests:

• Show both your Medicare card and your Medicaid or QMB card each time you get care.
• If you get a bill for Medicare charges, tell the provider or debt collector that you're in the QMB program and can't be charged for Medicare deductibles, coinsurance, and copayments.
• Your Medicare Summary Notice (MSN) can show that you're in QMB. Keep it to show the provider.

If a provider keeps billing you, call 1-800-MEDICARE (1-800-633-4227).

Why might I still get a bill?

Even with both programs, you might see a bill for:

• Services neither program covers. Some items aren't covered by Medicare or your state's Medicaid.
• A provider who doesn't take Medicaid. Medicaid pays only providers who accept it. Ask before your visit.
• Small Medicaid copays. Depending on your state, Medicaid may have small copays for certain services. Check with your state Medicaid office.
• Drug copays. Extra Help lowers drug costs, but you may still have small copays.
• A billing mistake. The provider may not have billed Medicaid after Medicare paid, or may not know you're in QMB.

How do I check a bill when I have both?

1. Find the Medicare payment. Look at your MSN or your plan's Explanation of Benefits (EOB).
2. Check whether Medicaid was billed. Call the provider and ask, "Did you bill my Medicaid after Medicare paid?"
3. If you're in QMB, say so, and ask them to remove Medicare cost sharing from your bill.
4. Ask if the service is covered by your state's Medicaid.
5. Keep your cards and notices handy. Copies of your Medicaid card and an MSN showing QMB can settle things quickly.

What about Medicare Advantage plans for dual eligibles?

Some Medicare Advantage plans, called Dual Eligible Special Needs Plans (D-SNPs), are designed for people with both Medicare and Medicaid. They may help coordinate benefits. Whether one makes sense depends on your state, your doctors, and your needs. A State Health Insurance Assistance Program (SHIP) counselor can help you compare options for free.

How do I apply for Medicaid or a Medicare Savings Program?

Apply through your state Medicaid office. Each state sets its own income and resource limits, and some count things differently, so it's worth applying even if you aren't sure you qualify. Medicare's booklet on Medicaid basics explains how to get started.

When you apply, have these ready:

• Your Medicare card.
• Proof of income, like a Social Security benefit letter or pension statement.
• Bank statements.
• Proof of where you live.

A SHIP counselor can help you fill out the application for free. Find yours at shiphelp.org or call 1-800-MEDICARE.

Frequently asked questions

If I have Medicare and Medicaid, who pays first?

Medicare pays first for Medicare-covered services. Medicaid pays after Medicare.

Do dual eligibles get Extra Help?

Yes. Medicare.gov says you'll automatically get Extra Help with drug costs.

Can a doctor bill me if I have QMB?

No, not for Medicare-covered services. Medicare.gov says Medicare providers aren't allowed to bill QMB members for Medicare deductibles, coinsurance, or copayments.

Who covers my prescriptions if I'm dual eligible?

Medicare drug coverage, not Medicaid.

Getting bills you think you shouldn't?

Bill Review Coach is a monthly medical bill review service for seniors and their families. Snap a photo of the bill and your Medicare notice, and we'll check whether Medicaid or QMB should have covered it and give you the words to say to the billing office. You make the calls and write the emails; we help you know what to say.