Dual Eligibility for Medicare and Medicaid: How It Works

The Arizona Health Care Cost Containment System (AHCCCS) is Arizona’s State Medicaid Program. AHCCCS Members who also have Medicare are called Dual Eligible Members. These members mostly receive their primary health insurance coverage through Medicare and some assistance from AHCCCS.

Dual Eligibility allows individuals to qualify for both Medicare and Medicaid benefits concurrently, with each federal program covering different aspects of their health care needs. Arizona health plans under Dual Eligibility typically include medical care coverage as well as prescription drug coverage that both Medicare and Medicaid can provide.

For example, D-SNP (Dual-Special Needs Plan) is a type of Medicare Advantage Plan contracted with AHCCCS, and offered by private insurance companies, that is available only to AHCCCS Dual Eligibles. D-SNP plans offer attractive supplemental benefits such as dental, vision, hearing, and grocery and utility bill assistance, and can better coordinate Medicaid and Medicare coverages for individuals with complex medical issues or disabilities.

In order to qualify for the Dual Eligible program, people must meet certain financial criteria and must be categorized as having a physical or mental disability, whether that disability is temporary or permanent. However, people who are 65 years old or older may qualify if their income meets the financial requirements of Medicaid. In other words, if your gross monthly income does not exceed the maximum allowed for eligibility in AHCCCS, among other requirements.

If this sounds confusing, that’s because it probably is. Enrolling in two single-payer health plans can be incredibly complex, especially for those with advanced health care needs. It is highly recommended that anyone seeking Dual Eligibility consult with an independent, licensed professional that can walk you through every aspect of each plan, including out of pocket costs, premiums and copays. Our representatives here at Insurance Professionals of Arizona will assist you with every step of the process.

For those who are eligible, Dual Eligibility can offer extensive health coverage from both public and private health insurers, help with prescription drug costs, coverage for medical care in skilled nursing facilities, dental services not available through traditional Medicare plans, and long-term care coverage. By and large, Dual Eligible members tend to have little to no income or savings, yet have significant disabilities that require substantial medical care.

Dual eligibility also allows for a higher level of security than traditional Medicare does on its own due to the broader coverage options of Medicaid. The financial burden of medical care is also much lighter on those enrolled in dual eligibility as one’s income will be taken into account when determining co-pays or other related expenses.

The most important step is knowing whether you meet the eligibility criteria for both federal programs. First, you must meet the requirements to qualify for Medicare which are based on age, disability or end-stage renal disease, while Medicaid eligibility depends on income level and other factors including certain health issues that may disqualify an individual from other forms of coverage.

If you believe you are qualified for Dual Eligibility, you may begin the application process. However, considering the importance of the application for a senior citizen living on limited means, it’s always a good idea to enlist help from an expert to make sure no part of the application is missing information or otherwise overlooked, and that best practices are employed. Should you be denied, a licensed expert can also assist you with the appeals process, identifying the initial issue that caused your denial and initiating corrective action.

Should you be approved, again, to ensure you fully understand the options and policies available to you, especially how these two programs interact with each other in order to maximize coverage at the lowest costs, it’s best to speak with a licensed insurance professional like the agents at IPA. It does not cost you anything out of pocket to do so.