Dual Eligibility: Medicaid and Medicare

Medicaid provides free or low-cost health care coverage to qualified people of all ages with low incomes, including children, pregnant women, older people, and people with disabilities.

With Medicaid expansion in Kentucky, it is available to adults aged 19-64 with incomes up to 138% of the Federal Poverty Level (FPL) and to pregnant women with incomes up to 200% FPL.

Some people may be “dual eligible.” This means they qualify for both Medicare and Medicaid. So, when a person meets criteria for both Traditional Medicare (Parts A and B) and Medicaid, they are considered “dually eligible.”

For those who are dual eligible, Medicare always acts as the primary insurance, while Medicaid steps in to fill the gaps, helping to pay for costs that Medicare doesn’t cover, such as premiums, deductibles, and co-insurance. Think of them as two puzzle pieces that work together to pay for your health care expenses.

Many dual-eligible individuals have multiple chronic conditions, behavioral health needs, and/or long-term services and support needs.

While all dual-eligible individuals have Medicare and some Medicaid benefits, their level of benefits may vary.

Dual-eligible beneficiaries (sometimes called “duals”) are enrolled in Medicare Parts A and/or B, and in Medicaid and/or in Medicare Savings Programs (MSPs). MSPs cover costs such as Parts A and/or B premiums and Parts A and B deductibles, coinsurance, and copayments, depending on the program. They may also help to cover prescription drug costs. While Medicare is administered by the federal government, Medicare Savings Programs are administered by the state; income qualifications can vary from state to state.

Medicare pays first when an individual is dually eligible and receives Medicare-covered services. Medicaid pays last, after Medicare and any other health insurance the individual has.

Similar to individuals who are not dual eligible, a person who qualifies for dual eligibility has the option of choosing Traditional Medicare or enrolling in a Medicare Advantage plan.

There are two types of dual eligibility, full and partial. Both are administered through Medicare Savings Programs (MSPs).

Full dual eligibility means that the individual meets the criteria for Medicare, as well as the requirements for Medicaid in their state. This allows them to receive not only the benefits conferred by Medicare, but also benefits covered by Medicaid that may not/are not covered by Medicare, such as dental, vision, and long-term custodial care. The Medicaid benefits available to those who are fully dually eligible can vary from state to state. I’ll explain this a bit more in a minute, but those who have full dual eligibility fall into the MSP groups with the additional signifier of “plus.”

Partial dual eligibility means that the individual does not qualify for full Medicaid benefits, but, based on income and resources, may qualify under one of the other MSP resource categories. Depending on the Medicare Savings Program for which they qualify, Medicaid will pay for some or all of their Medicare Parts A and B premiums and cost-sharing. Because Partial-Benefit Dual Eligible Individuals do not qualify for full Medicaid benefits, they do not receive additional Medicaid-covered benefits, such as long-term services or supports.

Qualified Medicare Beneficiaries are those with the fewest assets. The Qualified Medicare Beneficiary (QMB) program helps pay for Medicare Parts A and B premiums, deductibles, coinsurance, and copays, with eligibility set at 100% of the FPL. QMB is the most comprehensive MSP, covering all Medicare costs, including help with prescription costs.

The next level is called the Specified Low-Income Medicare Beneficiary (SLMB). This covers Medicare Part B premiums, with eligibility generally set between 100% and 120% of the FPL, and it also provides help with prescription drug costs. Neither this program nor the ones that follow cover copays, deductibles, or coinsurance costs.

The Qualifying Individual (QI) program, often called QI-1, helps pay Medicare Part B premiums for individuals with incomes above the Specified Low-Income Medicare Beneficiary (SLMB) level but below 135% of the FPL. However, states use limited federal funds for this program, so it’s limited to first-come, first-served. Those who seek QI assistance must reapply every year to remain in the program. Similar to QMB and SLMB, it helps with prescription drug costs.

Lastly, the Qualified Disabled and Working Individual (QDWI) program helps pay Medicare Part A premiums for people under age 65 with disabilities who lost their Social Security disability benefits and free Medicare Part A because they went back to work. To qualify, their income level must be below 200% of the FPL.

Income limits are based on a percentage of the FPL. The Centers for Medicare and Medicaid Services has officially updated the resource or asset limits for most MSPs. For QMB, SLMB, and QI programs, these have increased to $9,950 for individuals and $14,910 for couples in 2026. These represent the maximum “countable” assets, such as savings, stocks, and bonds, that a person can have to qualify.

This chart shows the benefits covered by Medicaid within the MSPs in table form, which is sometimes easier to understand.