Approximately 12.5 million Americans qualify for both Medicare and Medicaid—known as dual eligibles or dually eligible beneficiaries. Dual eligibility provides comprehensive healthcare coverage at minimal or no cost by combining Medicare's broad coverage with Medicaid's wrap-around benefits and financial assistance. Understanding dual eligibility, Medicare Savings Programs, and Extra Help benefits is essential for millions of low-income seniors who may qualify for substantial assistance they don't currently receive. These programs can reduce healthcare costs by thousands of dollars annually while providing more comprehensive coverage.
Understanding Dual Eligibility: Medicare and Medicaid Together
Dual eligibility occurs when someone qualifies for both Medicare and Medicaid simultaneously. Medicare serves as the primary insurance, covering hospital care, medical services, and prescription drugs. Medicaid then provides secondary coverage, paying Medicare premiums, deductibles, and cost-sharing that Medicare beneficiaries would otherwise pay out-of-pocket, plus additional services Medicare doesn't cover like long-term care, dental, vision, and transportation to medical appointments.
Full-benefit dual eligibles receive comprehensive Medicaid benefits including all services their state Medicaid program covers. This typically includes long-term care in nursing facilities, home and community-based services, dental care, vision care, hearing aids, and other services not covered by Medicare. Medicaid pays Medicare Part A premiums (if applicable), Part B premiums, all Medicare deductibles, and Medicare coinsurance, meaning dual eligibles typically have zero or minimal out-of-pocket costs for healthcare.
Partial-benefit dual eligibles qualify for Medicare Savings Programs that help pay some or all Medicare premiums and cost-sharing but don't receive full Medicaid benefits. These individuals have income too high for full Medicaid but low enough to need help with Medicare costs. Several Medicare Savings Programs provide varying levels of assistance based on income.
Dual eligibles also automatically qualify for Extra Help (the Low-Income Subsidy) with Part D prescription drug costs, substantially reducing medication expenses. Extra Help pays most or all Part D premiums, eliminates the Part D deductible, and limits copays to $4.50 for generic drugs and $11.20 for brand-name drugs in 2025 for those with the highest level of assistance. Some dual eligibles pay even less—$0 copays—for medications.
Special rules benefit dual eligibles. They can change Medicare Advantage or Part D plans monthly if they're unhappy with coverage, providing exceptional flexibility unavailable to other Medicare beneficiaries. Dual eligible individuals are protected from Medicare Advantage and Part D plan mid-year formulary changes, utilization management restrictions, and certain cost increases.
Medicare Savings Programs: QMB, SLMB, QI, and QDWI
Medicare Savings Programs help pay Medicare premiums and, in some cases, deductibles and cost-sharing for people with limited income and resources. Four programs exist, each with different eligibility requirements and benefits. These programs are administered by state Medicaid agencies but help specifically with Medicare costs.
Qualified Medicare Beneficiary (QMB) Program provides the most comprehensive assistance. QMB pays your Medicare Part A premium (if you have one), Part B premium ($185 monthly in 2025), Medicare Part A and Part B deductibles, and Medicare Part A and Part B coinsurance. Effectively, QMB beneficiaries have no out-of-pocket costs for Medicare-covered services when seeing providers who accept QMB.
To qualify for QMB in 2025, your income must be at or below 100% of the federal poverty level ($15,060 annually for individuals, $20,440 for couples), and your resources must not exceed $9,430 for individuals or $14,130 for couples. Resources include bank accounts, stocks, and bonds, but not your home, one vehicle, household goods, or personal items.
QMB participation means healthcare providers cannot bill you for Medicare cost-sharing on Medicare-covered services. However, providers can bill you for services Medicare doesn't cover, like routine dental care or hearing aids. Understanding what Medicare covers helps you know when you should and shouldn't receive bills.
Specified Low-Income Medicare Beneficiary (SLMB) Program pays your Part B premium but doesn't cover deductibles or coinsurance. For 2025, this means $185 monthly assistance—$2,220 annually. To qualify for SLMB, your income must be between 100% and 120% of the federal poverty level ($15,061-$18,072 for individuals, $20,441-$24,528 for couples), and resources must not exceed the same limits as QMB: $9,430 for individuals or $14,130 for couples.
SLMB beneficiaries automatically qualify for Extra Help with Part D costs, providing substantial additional assistance with prescription drugs even though SLMB itself doesn't cover drug costs. The combination of Part B premium assistance and Part D Extra Help provides significant financial relief.
Qualifying Individual (QI) Program also pays the Part B premium for people with income between 120% and 135% of the federal poverty level ($18,073-$20,331 for individuals, $24,529-$27,594 for couples in 2025). Resource limits match QMB and SLMB levels. QI beneficiaries also automatically qualify for Extra Help with Part D.
QI eligibility is determined on a first-come, first-served basis each calendar year because the program has limited federal funding. This means applying early in the year improves your chances of qualifying. If you're denied QI due to funding limitations, reapply early the following January.
Qualified Disabled and Working Individual (QDWI) Program helps certain disabled individuals under age 65 who lost premium-free Part A when they returned to work. QDWI pays the Part A premium if your income is below 200% of the federal poverty level and resources don't exceed QMB limits. This program is rarely used but provides important assistance for younger disabled individuals returning to work.
Extra Help: Low-Income Subsidy for Part D Costs
Extra Help, formally called the Low-Income Subsidy (LIS), helps pay Medicare Part D prescription drug plan costs including premiums, deductibles, and copays. Approximately 13 million Medicare beneficiaries receive Extra Help, though millions more who qualify don't apply. This program provides critical assistance making medications affordable for people with limited income.
Extra Help has two assistance levels. Full Extra Help is for individuals with income below 135% of the federal poverty level and resources below $10,930 (individuals) or $17,220 (couples) in 2025. Full Extra Help pays the entire Part D premium up to a benchmark amount (most plans fall below this benchmark), eliminates the Part D deductible entirely, and limits copays to $4.50 for generic drugs and $11.20 for brand-name drugs. Some individuals with the lowest incomes pay $0 copays.
Partial Extra Help is for individuals with income between 135% and 150% of the federal poverty level and resources below $16,830 (individuals) or $33,600 (couples). Partial Extra Help provides reduced assistance with premiums, no deductible, and copays of 15% of drug costs up to the catastrophic coverage threshold.
With Extra Help, you're not subject to the Part D coverage gap (though this is now eliminated for all Part D beneficiaries as of 2025 with the $2,000 out-of-pocket cap). More importantly, Extra Help's low copays apply throughout the year with no increase, making budgeting for medications much easier. The $35 monthly insulin cap applies to Extra Help beneficiaries as well, though many already pay less under Extra Help's copay structure.
Extra Help recipients can change Part D plans or Medicare Advantage plans with drug coverage during Special Enrollment Periods: once per calendar quarter during the first three quarters (January-September) and once during the fourth quarter (October-December). This flexibility allows switching to plans with better formularies or lower out-of-pocket costs if your current plan doesn't serve your needs.
Some people qualify for Extra Help automatically—deemed eligible—without applying. This includes anyone receiving Supplemental Security Income (SSI), anyone who has full Medicaid coverage, or anyone who qualifies for a Medicare Savings Program. If you're deemed eligible, you automatically receive Extra Help without a separate application.
For those not automatically eligible, you can apply for Extra Help through Social Security online at ssa.gov/medicare/prescriptionhelp, by phone at 1-800-772-1213, at your local Social Security office, or by completing a paper application and mailing it to Social Security. You can also apply through your state Medicaid office, as applications are coordinated between Social Security and Medicaid.
Income and Asset Limits for Dual Eligibility Programs 2025
Understanding income and asset limits is crucial for determining eligibility for dual eligibility programs. Limits are updated annually and vary by program. For 2025, federal poverty levels that determine Medicare Savings Program and Extra Help eligibility are $15,060 for individuals and $20,440 for married couples, with higher amounts for Alaska and Hawaii.
Income calculations include wages, Social Security benefits, pensions, interest, dividends, and most other regular income. Some income exclusions apply, varying by program and state. States have some flexibility in how they calculate income for Medicare Savings Programs, with some states using more generous methodologies that exclude additional amounts. Your state Medicaid office can explain exactly what counts as income in your state.
Resource (asset) limits for Medicare Savings Programs in 2025 are $9,430 for individuals and $14,130 for married couples. Resources include checking and savings accounts, stocks, bonds, mutual funds, and certain other financial assets. Importantly, several things don't count as resources: your home, one vehicle regardless of value, household goods and personal items, life insurance with face value under $1,500, burial plots, and up to $1,500 in burial funds per person.
For Extra Help, resource limits are higher. Full Extra Help resource limits are $10,930 for individuals and $17,220 for couples. Partial Extra Help resource limits are $16,830 for individuals and $33,600 for couples. The same types of assets are excluded from Extra Help resource calculations as from Medicare Savings Programs.
If your income or resources slightly exceed the limits, don't assume you're ineligible without applying. States may use more generous eligibility rules, allow certain deductions that reduce countable income, or have state-funded programs that extend eligibility beyond federal minimums. Additionally, if you're married and your spouse doesn't have Medicare, different rules may apply to how your household income and resources are calculated.
How to Apply for Dual Eligibility and Assistance Programs
Applying for dual eligibility programs and Medicare Savings Programs requires contacting your state Medicaid agency. Each state administers these programs through its Medicaid office, though the programs are funded partially or fully by the federal government. Find your state Medicaid office contact information by calling 1-800-MEDICARE or visiting medicare.gov and searching for Medicare Savings Programs.
Application processes vary by state but generally require completing a Medicaid or Medicare Savings Program application form, providing proof of income (Social Security award letters, pay stubs, pension statements, bank statements showing interest income), providing proof of resources (bank statements for all accounts, stock and bond statements, documentation of other financial assets), providing proof of Medicare enrollment (Medicare card), and providing Social Security number and citizenship or legal residency documentation.
Many states allow applications online, by mail, by phone, or in person. State Health Insurance Assistance Programs (SHIP) can help you complete applications free of charge. Local Area Agencies on Aging also frequently provide application assistance. Don't let the application process intimidate you—help is available.
Processing times vary by state, typically ranging from 45 to 90 days. If you're eligible, coverage is often retroactive to the month you applied or the month you first became eligible. If denied, you have appeal rights. Denials must explain the reason and your right to appeal. Many denials are due to incomplete documentation or calculation errors and can be overturned on appeal.
For Extra Help, apply through Social Security as described earlier. The Extra Help application is simpler than full Medicaid applications. Social Security can often process Extra Help applications more quickly, sometimes within weeks. If you apply for a Medicare Savings Program, ask whether that application also serves as an Extra Help application to avoid filing duplicate applications.
Once enrolled in these programs, you must recertify eligibility periodically—typically annually. Your state will mail renewal forms before your coverage expires. Complete and return these forms promptly with updated income and resource documentation. Missing renewal deadlines can result in coverage termination, requiring you to reapply and potentially losing months of assistance.
Additional Benefits for Dual Eligibles
Beyond financial assistance with Medicare costs, dual eligibles often receive additional benefits not available through Medicare alone. Long-term services and supports represent the most significant additional benefit. Medicaid covers nursing home care beyond the limited coverage Medicare provides, and increasingly, Medicaid covers home and community-based services that help people remain in their homes rather than entering nursing facilities.
Dental coverage through Medicaid varies significantly by state. All states cover emergency dental services, but comprehensive dental coverage including routine cleanings, fillings, dentures, and other services depends on your state's Medicaid program. This dental coverage fills a critical gap since Medicare doesn't cover routine dental care.
Vision services beyond what Medicare covers are typically included in Medicaid, often covering routine eye exams, eyeglasses, and sometimes more extensive vision care. Hearing services including hearing exams and hearing aids may be covered by Medicaid in your state, addressing another major Medicare coverage gap.
Non-emergency medical transportation to medical appointments is frequently covered by Medicaid. If you don't have reliable transportation to doctor appointments, Medicaid can arrange and pay for transportation, ensuring you can access necessary healthcare. This benefit prevents missed appointments and untreated conditions due to transportation barriers.
Some states provide care coordination or care management services for dual eligibles, particularly those with complex medical conditions. Care coordinators help navigate the healthcare system, coordinate services between providers, ensure you understand treatment plans, and connect you with community resources. This support improves health outcomes and reduces confusion navigating complex dual coverage.
Dual Eligible Special Needs Plans (D-SNPs)
Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs) are specialized Medicare Advantage plans designed specifically for people with both Medicare and Medicaid. These plans coordinate Medicare and Medicaid benefits, often providing more integrated and comprehensive care than managing Medicare and Medicaid separately.
D-SNPs must provide all Medicare-covered services plus care coordination, connecting you with Medicaid services and community supports. Many D-SNPs include additional benefits like dental, vision, and hearing services beyond what standard Medicare Advantage plans offer. Some D-SNPs partner with state Medicaid programs to cover both Medicare and Medicaid services through a single integrated plan.
To enroll in a D-SNP, you must have both Medicare and Medicaid (or qualify for a Medicare Savings Program). D-SNPs typically have $0 premiums beyond the Part B premium, minimal or no copays for services, and simplified access to care through coordinated networks. If you're dual eligible, comparing available D-SNPs to Original Medicare with your Medicaid wrap-around coverage can help determine which approach provides better coordinated care in your specific situation.
Protecting Your Dual Eligibility Benefits
Once you qualify for dual eligibility programs, protect these valuable benefits by reporting income and asset changes promptly to your state Medicaid office, completing recertification forms on time each year, keeping copies of all applications and correspondence with Medicaid, understanding your appeal rights if benefits are reduced or terminated, and seeking assistance from SHIP counselors or legal services if you encounter problems with coverage.
If your income or resources increase above program limits, you might lose eligibility. However, temporary income increases don't always affect eligibility—consult with your Medicaid office about how specific changes impact your coverage before assuming you no longer qualify. Some states have provisions allowing continued eligibility despite minor income increases.
Dual eligibility and Medicare Savings Programs provide life-changing assistance for millions of Americans with limited income and resources. If you struggle to afford Medicare premiums, deductibles, copays, or prescription drugs, you may qualify for help even if you've never received public assistance before. The application process is worth the effort—these programs can reduce your healthcare costs by thousands of dollars annually while ensuring you receive comprehensive care. Don't let pride, stigma, or misconceptions prevent you from applying for benefits you've earned and deserve.