Dual eligibility - having Medicaid and Medicare
Dual-eligible beneficiaries are individuals enrolled in both Medicare and Medicaid. There are two types of duals:
- Full duals: receive full Medicaid benefits in addition to Medicare
- Partial duals: receive help with Medicare premiums and cost-sharing through Medicare Savings Programs (MSPs), but may not have full Medicaid benefits
Who qualifies for dual eligibility?
To qualify for dual eligibility, you must be enrolled in Medicare Part A and/or Part B, and be a full or partial dual.
How does dual-eligibility work?
In short, it's like having two health plans that covers the cost of your health care: Medicare and Medicaid.
Medicare is health insurance for:
- People who are age 65 and older
- Certain people under age 65 with disabilities and entitled to Social Security disability or Railroad Retirement Board benefits
- People of any age with Early Stage Renal Disease (ESRD)
Medicaid is a joint federal and state program that provides health insurance for certain people with low income. Each state administers its own program, following federal guidelines, statutes, regulations, and policies. In Oregon, our Medicaid is called the Oregon Health Plan. CareOregon is an administrator of the Oregon Health Plan.
Who pays for services?
For medical services
The Medicare plan acts as the primary payer for health services, like doctor visits and hospital stays. Medicaid is the second payer and covers Medicare premiums, deductibles, and cost-sharing. Medicaid often provides extra benefits like long-term care, dental care, vision services and non-medical transportation.
Medicamentos recetados
In most cases, dual-eligibles pay little to no cost for their prescription drugs based on their income. The Medicare Part D low income subsidy (LIS) program, also referred to as the Extra Help Program, helps pay for drug plan monthly premiums, annual deductibles, and copayments for those who have or want Part D coverage and meet certain income and resource limits.
Dual-eligible individuals automatically qualify for Extra Help.
Special Needs Plans (D-SNPs)
Many dually eligible individuals enroll in Dual Eligible Special Needs Plans (D-SNPs), a type of Medicare Advantage plan that combines both programs for coordinated care. CareOregon offers a D-SNP plan called CareOregon Advantage Plus (HMO D-SNP) that provides and coordinates care for dual eligibles in certain areas of Oregon.