Glossary Term

Dual Eligible

A Dual Eligible refers to an individual who is simultaneously eligible for Medicare and Medicaid. Medicare is a federal program providing primary medical coverage to senior citizens and, to a lesser degree, the disabled population. Medicaid is a joint federal-state program financing primary medical coverage to low-income individuals, pregnant women, children, and other populations as well as long-term care coverage to many seniors and people with disabilities.

The Centers for Medicare & Medicaid Services reported that there were 12.3 million dual eligibles in 2019 with 37.9 percent of them under the age of 65. Under-age individuals can qualify for Medicare by virtue of conditions such as disability or end-stage renal disease (ESRD). The Kaiser Family Foundation has noted that while dual-eligibles account for 17 percent of traditional Medicare beneficiaries, they represent 33 percent of that program’s costs. CMS has also observed that dual eligibles are less healthy as a group than the general Medicare population, with fifteen percent of dual eligibles self-reporting a “poor” health status compared to only four percent for all Medicare beneficiaries.

Dual eligibles automatically qualify for the Medicare Part D Low-Income Subsidy, otherwise known as the Extra Help program. The Low-Income Subsidy provides Medicare Part D premium assistance and reduces out-of-pocket obligations for deductibles, copayments, and coinsurance. Dual eligibles also qualify to join certain Special Need Plans (SNPs) that provide Medicare Advantage coverage in a manner tailored to the needs of the dual eligible population.

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