Dual Eligibility: Having Both Medicare and Medicaid

Most people who get Long-Term Care Medicaid also have Medicare. People who have both are called dual eligibles. The two programs work together: Medicare pays first for the medical care it covers, and Medicaid fills many of the gaps, including long-term care and, often, Medicare’s premiums and cost-sharing. This guide explains how the combination works, the different levels of dual eligibility and what it means for a person in a nursing home or receiving care at home.

Figures change periodically. Double-check current amounts before relying on them.

Two kinds of dual eligibles

A person on Long-Term Care Medicaid is a full-benefit dual eligible if they also have Medicare.

Who pays first

When a person has both programs, Medicare pays first for services it covers, such as hospital stays, doctor visits, short skilled nursing stays and prescription drugs (through Part D). Medicaid pays second, for:

• services Medicare does not cover, most importantly long-term custodial care in a nursing home or at home;
• Medicare cost-sharing, such as deductibles and coinsurance, for those who qualify;
• Medicare premiums, for those who qualify.

Medicaid is the “payer of last resort.” It pays only after Medicare and any other insurance.

The Medicare Savings Programs

Even people who do not qualify for full Medicaid may get help with Medicare costs through the Medicare Savings Programs (MSPs), which are run by state Medicaid agencies. The federal 2026 limits are:

The income limits are slightly higher in Alaska and Hawaii. Some states use more generous rules or do not count certain income or resources, so people above these figures may still qualify. QI is first-come, first-served and must be renewed each year.

Note how much higher the MSP resource limits are than the typical $2,000 Long-Term Care Medicaid limit. A person who does not yet qualify for nursing home Medicaid may still qualify for an MSP.

What dual eligibility means in practice

Part B premium

The standard Part B premium in 2026 is $202.90 a month. For a full-benefit dual eligible or a person in an MSP that covers it, the state pays the premium, and Social Security stops deducting it from the monthly check. That raises the person’s net Social Security payment.

For a nursing home resident on Medicaid, this matters for the patient liability: once the state pays the premium, it is no longer deducted from income, so the amount owed to the nursing home usually goes up by the same amount. The person is not worse off overall; the money simply flows differently.

Prescription drugs

Dual eligibles get their drugs through Medicare Part D, not Medicaid. They automatically qualify for Extra Help (the Part D low-income subsidy), which lowers premiums and copays. People who qualify for a QMB, SLMB or QI program also get Extra Help. Nursing home residents on Medicaid generally pay no Part D copays.

Dual eligibles can generally change Part D plans more often than other people, within limits set by Medicare.

Billing protections

People in the QMB program cannot be billed by Medicare providers for Medicare deductibles, coinsurance or copays for Medicare-covered services. If a provider bills a QMB enrollee for these amounts, the enrollee should tell the provider they are in QMB and show their Medicaid or QMB card.

Skilled nursing stays

During a Medicare-covered skilled nursing stay, Medicare pays the full cost for days 1 to 20. For days 21 to 100, the coinsurance is $217 a day in 2026. For a full-benefit dual eligible or a QMB enrollee, Medicaid generally covers this coinsurance (within the state’s payment rules). When Medicare coverage ends, Medicaid continues to pay for long-term care if the person qualifies.

Plans for dual eligibles

Many dual eligibles can choose special plans that combine Medicare and Medicaid:

• Dual Eligible Special Needs Plans (D-SNPs) are Medicare Advantage plans for people with both programs. Some coordinate closely with Long-Term Care Medicaid.
• Integrated plans, available in some states, combine Medicare and Medicaid benefits, including long-term care, under one plan.
• PACE (Program of All-Inclusive Care for the Elderly) serves people 55 and older who meet nursing home level of care and can live safely in the community, combining all Medicare and Medicaid services.

These options vary a lot by state and county. People can usually stay in Original Medicare if they prefer.

A worked example

Edna, 88, is in a nursing home and has just been approved for Long-Term Care Medicaid. She has $1,500 a month in Social Security before the Part B premium is deducted, and her state’s personal needs allowance is $60 a month.

Before the state starts paying her Part B premium:

• Social Security deducts $202.90, and Edna receives $1,297.10.
• Her patient liability is her gross income ($1,500), minus the $60 allowance and minus the $202.90 premium she is paying: $1,237.10.

After the state starts paying the premium:

• Social Security no longer deducts the premium. Edna receives $1,500.
• Her patient liability is $1,500 minus $60: $1,440.

Either way, Edna keeps $60 a month. It often takes a few months for the state’s premium payment to begin, and Social Security may later refund premiums deducted after the state became responsible. That refund belongs to Edna but can count as an asset if it is kept past the month it arrives, so plan for it.

Common questions

Do I need to apply separately for a Medicare Savings Program? People approved for full Medicaid usually have their Medicare premiums handled automatically. Others apply for an MSP through the state Medicaid agency.

Will I lose my Medigap policy? Medigap is not usually needed once full Medicaid covers Medicare cost-sharing. Federal rules let a person suspend a Medigap policy for up to 24 months while on Medicaid. Talk to the insurer before cancelling.

Can I keep my Medicare Advantage plan? Usually, yes. But check that the nursing home or home care provider works with both the plan and Medicaid.

What if I have a retiree health plan? It usually pays before Medicaid. Premiums for health insurance can be deducted when figuring patient liability.

Does Medicaid pay for things Medicare covers if my provider does not accept Medicaid? Medicare still pays its share. Whether Medicaid pays the cost-sharing depends on whether the provider takes Medicaid and on state rules.

Steps to take

1. Make sure Medicare Part A and Part B are in place. Long-Term Care Medicaid applicants who are eligible for Medicare are generally expected to enroll.
2. If income and resources are modest, apply for a Medicare Savings Program even if full Medicaid is not yet possible.
3. When Long-Term Care Medicaid is approved, watch for the change in the Social Security deposit and the patient liability.
4. Review the Part D plan to make sure the person’s drugs are covered at their pharmacy or nursing home.
5. A Certified Medicaid Planner (CMP) can help coordinate the timing of Medicare, Medicaid and other coverage.

Key terms

When full Medicaid ends

If a person loses full Medicaid, for example because their assets rise above the limit after an inheritance, they may still qualify for a Medicare Savings Program, which has higher resource limits. Request a Medicare Savings Program review before coverage ends, so the Part B premium does not suddenly come out of the Social Security check again. Also check whether the person still qualifies for Extra Help with drug costs, which has its own resource limit and application through Social Security. Keep copies of every notice about these changes, since errors in premium billing are common and are easier to fix with paperwork in hand.

Related guides

• Medicaid vs. Medicare for long-term care
• SSI and Medicaid
• Patient liability
• 2026 figures at a glance

Last updated for 2026. General information only, not legal or financial advice. Medicaid Answers is a free educational resource published by Medicaid Answers Foundation.