Dual-Eligible Programs

What does it mean to be dual-eligible?

The term dual-eligible in Medicare terminology means you are eligible for both Medicare and Medicaid. About 12 million Americans are enrolled in both Medicare and Medicaid, meaning that their insurance plan is Medicare but Medicaid pays for some of the out-of-pocket expenses. There are also some Medicare Advantage Plans you are eligible for as a dual-eligible applicant. Read on to learn more.

Medicare vs. Medicaid

To understand what it means to be dual-eligible, you first have to understand the differences between Medicare and Medicaid. 

Medicare is a federal health insurance plan offered to three populations: people 65 and older, younger people with disabilities, and younger people with End Stage Renal Disease (ESRD). To be eligible for Medicare, you have to belong to one of these groups. Medicare pays like any other insurance plan, meaning that it covers many things but there are also many out-of-pocket costs.

Medicaid is an income-based fee assistance program. It helps low-income people pay for their healthcare. Anyone of any age and any medical issue can apply for Medicaid provided they meet the low-income standard set by their state.

Types of Dual-Eligible Programs

Being dual-eligible means that your healthcare costs will dramatically decrease. However, there are different levels of dual-eligibility to be aware of. Not all programs are created equal. Some will pay more than others. The four different types of dual eligible programs and their payment types are:

Qualified Medicare beneficiary (QMB) Program: pays portions of Part A, Part B, or both Program premiums, deductibles, coinsurance, and copayments

Specified Low-Income Medicare beneficiary (SLMB) Program: helps pay Part B premiums

Qualifying Individual (QI) Program: Pays part of Part B premiums but on a first-come first-serve basis

Qualified Disabled Working Individual (QDWI) Program: helps pay Part A premiums for some disabled and working beneficiaries under 65 who don’t get Medicaid but do have limited income according to their state’s criteria

Dual-Eligible Medicare Advantage Special Needs Plans

If you are dual-eligible, you may also be eligible for a special type of Medicare Advantage Plan. Medicare Advantage, also called Medicare Part C, is an addition to Original Medicare that offers bonuses, like gym membership, vision coverage, dental coverage, etc. Medicare Advantage Plans are sold by private insurers, so the exact coverage details depend on the plan. 

A Dual-Eligible Special Needs Plan, D-SNP, is a specific type of Medicare Advantage Plan. It helps decrease patients’ out-of-pocket healthcare costs. Both state and federal governments contribute to that patient’s costs. They also offer additional benefits, like fitness, smoking cessation, transportation, hearing aids, vision coverage, meals, and some over-the-counter products. Some D-SNPs also include prescription coverage. Lastly, these plans require healthcare teams to work together to create an overarching healthcare plan.


If you’re eligible for both Medicare and Medicaid, you’re considered dual-eligible. This means that your healthcare costs will dramatically increase. There are a number of dual-eligible programs and a specific Medicare Advantage Plan type. Contact us at Generations Insurance to learn more about your options.