Understanding Medicare and Medicaid
Medicare is a federal insurance program for people 65 and older or those with disabilities or certain medical conditions. It consists of four main parts: Part A (hospital services), Part B (outpatient services and doctor visits), Part C (Medicare Advantage), and Part D (prescription drug coverage).
Medicaid is a joint federal and state program that offers health coverage to low-income individuals and families. It covers a wide range of health care services including hospital stays, doctor visits, prescription drugs, mental health services, and long-term care. Medicaid benefits and eligibility can vary by state. Also, the program provides coverage for certain groups beyond low income, such as pregnant women and children.
Can you have Medicare and Medicaid at the same time?
Yes, you can qualify for both Medicare and Medicaid at the same time. This is called dual eligibility. This often occurs when individuals meet the criteria for both programs such as being over 65, disabled, or meeting low-income requirements. When this happens, Medicare pays for most of the health care costs first, and Medicaid helps with other costs like copays, deductibles, and services not covered by Medicare. This provides more coverage and reduces out-of-pocket costs for dual-eligible individuals.
Advantages of dual eligibility
Being dual eligible for Medicare and Medicaid can help because each covers different things. For example, Medicare covers hospital stays and doctor visits, while Medicaid can also help with long-term care and certain dental and vision services. This means that people with dual eligibility often get more comprehensive coverage, giving access to a wider range of care and services.
Dual-eligible plans in PA
UPMC Health Plan has two plans that work together to provide you with your health care coverage in Pennsylvania—UPMC for Life Complete Care (HMO D-SNP) and UPMC Community HealthChoices. You can enroll in these plans if you are eligible for both Medicare and Medical Assistance (Medicaid). When you’re a member of both UPMC for Life Complete Care and UPMC Community HealthChoices, we can more effectively coordinate your health care and make it less confusing. Plus, you get extra benefits to help you stay healthy and independent.
- UPMC for Life Complete Care is a Medicare Advantage (Part C) plan that gives you medical and prescription drug coverage. UPMC for Life Complete Care acts as your primary health care coverage. You have a $0 premium, $0 medical copays, and $0 copays for Tier 1 and Tier 2 prescriptions. You’ll also get vision, dental, and hearing care; transportation services; and unlimited gym memberships. Plus, you get additional allowance dollars to buy over-the-counter (OTC) and home safety products with the UPMC for Life Shop Healthy Card.
- UPMC Community HealthChoices is a Medicaid plan that provides secondary coverage for most of your medical, vision, and dental services. If you are eligible for long-term services and supports (LTSS), UPMC Community HealthChoices will coordinate and pay for these services along with your medical coverage.
If your UPMC for Life Complete Care plan does not fully cover something you need, UPMC Community HealthChoices may help cover the cost.* You’ll have only one member ID card and one point of contact for all your health care information.
Here’s how these plans work together to help you get the most out of your health care coverage.
With the UPMC for Life Shop Healthy Card, members get $60 every month to pay for OTC and home safety products. Members who qualify for Special Supplemental Benefits for the Chronically Ill will receive two additional allowances: $110 per month for healthy foods and $40 per month for household utilities.
This benefit is part of the Special Supplemental Benefits for the Chronically Ill (SSBCI) program. To be eligible, you must qualify for Low-Income Subsidy (LIS) and have one of the following chronic illnesses: chronic/disabling mental health conditions, metabolic disorders, cardiovascular disorders, substance use disorders, diabetes, or other eligible conditions not listed. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For details, please contact us.
- $0 copay for two oral cleanings and exams every year
- $3,995, $5,000 or $8,250 yearly allowance (depending on your plan) for additional dental services
- $0 copay for two oral cleanings and exams every year
- Restorations (fillings) and simple tooth removal
- Up to a $500 yearly allowance for certain dental services
UPMC for Life Complete Care:
- Unlimited FREE gym memberships through SilverSneakers® to participating fitness facilities plus one free personal training session each year
- The option to work out from the safety of home with in-home fitness kits
- $0 for one hearing exam and hearing aid fitting each year
- $0 copay per ear every year or every three years (depending on your plan) for hearing aids through Amplifon.
UPMC Community HealthChoices: Additional home safety products may be covered for those with Medicaid long-term services and supports based on your service plan.
- $0 copay for inpatient medical services
- $0 copay for outpatient medical services
- $0 copay for inpatient medical services
- $0 copay for outpatient medical services
UPMC for Life Complete Care prescription coverage:
- $0 copay for Tier 1 and Tier 2 prescription drugs
- Depending on the level of Extra Help you receive, you will have a $0, $1.60, $4.90, $5.10, or $12.65 copay for Tier 3, Tier 4, and Tier 5 prescription drugs
UPMC for Life Complete Care: Transportation to and from medical approved locations, including doctor’s offices, health care facilities, pharmacies, and fitness centers. Members who qualify for Special Supplemental Benefits for the Chronically Ill (SSBCI) can use some of their trips for nonmedical locations like grocery stores, places of worship, salons, banks, funeral homes, libraries, and adult day/community centers.
Depending on your plan, you get:
- 20 one-way trips to medical approved locations. For members who qualify for SSBCI, 8 of these 20 one-way trips may be to nonmedical locations. For members who qualify for SSBCI, 34 of these 60 one-way trips may be to nonmedical locations.**
UPMC Community HealthChoices: Nonmedical trips may be covered for those with Medicaid long-term services and supports based on your service plan.
- $0 copay for one routine vision exam and contact lens fitting each year
- $575 yearly allowance for eyewear or contact lenses
- $0 copay for two routine vision exams each year
- Specialist eye exam with PCP prescription
- Up to a $100 allowance every 12 months for one pair of glasses or contacts
- $0 copay for 24/7 medical advice over the phone from experienced registered nurses
- $0 copay for an online virtual visit with a UPMC provider***
- $0 copay for 24/7 medical advice over the phone from experienced registered nurses
- $0 copay for an online virtual visit with a UPMC provider***
Who Qualifies for Both Medicare and Medicaid?
To be dual eligible for both Medicare and Medicaid in Pennsylvania, you must meet specific criteria for each program. Below are the requirements for Medicare and Medicaid in Pennsylvania:
Medicare eligibility requirements:
- Age 65 or older
- Under 65 with certain disabilities
- Any age with end-stage renal disease or ALS
- U.S. citizen or lawfully present in the United States for five consecutive years before applying for Medicare
Medicaid eligibility requirements:
- Low-income, typically below a certain threshold determined by the state
- U.S. citizen or a legally present noncitizen
- A permanent resident of Pennsylvania
How to apply for Dual Medicare and Medicaid
Steps to apply for Medicare and Medicaid:
- Check eligibility. Make sure you meet the requirements for both Medicare and Medicaid. This includes age, disability status, income level, and residency.
- Gather documentation. Collect important documents such as proof of income, identification, Social Security number, and medical records.
- Apply for Medicare. If you are not already enrolled, apply for Medicare through the Social Security office. You can do this online, by phone, or by visiting your local Social Security office.
- Apply for Medicaid. Apply for Medicaid through your state’s Medicaid office or online portal.
- Wait for confirmation. Once you have submitted your information, wait to get confirmation that you are enrolled in both programs. You will get notices from Medicare and your state’s Medicaid office.
- Coordinate benefits. After you have enrolled, check your benefits to make sure you are getting the most out of both programs.
All UPMC for Life Complete Care allowance amounts are based on the 2026 benefit year. For more information about benefit allowances, call us at 1-844-575-8241 (TTY: 711).
*UPMC for Life Complete Care benefits must be used before UPMC Community HealthChoices benefits can be used.
**This benefit is part of the Special Supplemental Benefits for the Chronically Ill (SSBCI) program. To be eligible, you must qualify for Low-Income Subsidy (LIS) and have one of the following chronic illnesses: chronic/disabling mental health conditions, metabolic disorders, cardiovascular disorders, substance use disorders, diabetes, or other eligible conditions not listed. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For details, please contact us.
***UPMC for Life members who are in Pennsylvania at the time of a virtual visit may select a UPMC-employed provider, subject to availability and discretion of the provider. Members located outside of Pennsylvania at the time of service will receive care from a provider employed or contracted by Online Care Network II PC (OCN), also known as Amwell Medical Group. OCN is not an affiliate of UPMC. Providers are not available to treat members who are in Puerto Rico.
View our Caring for Life newsletter to learn more:
Issue 1, 2025
View our Caring for Life newsletter to learn more:
Learn more about the UPMC for Life Complete Care plans available in your area
This information is available for free in other languages. Please call our customer service number at 1-800-606-8648 (TTY: 711).
UPMC for Life has a contract with Medicare to provide HMO, HMO D-SNP, and PPO plans. The HMO D-SNP plans have a contract with the PA State Medical Assistance program. Enrollment in UPMC for Life depends on contract renewal. UPMC for Life is a product of and operated by UPMC Health Plan Inc., UPMC Health Network Inc., UPMC Health Benefits Inc., UPMC for You Inc., and UPMC Health Coverage Inc.
SilverSneakers is a registered trademark of Tivity Health Inc. SilverSneakers GO is a trademark of Tivity Health Inc. © 2025 Tivity Health Inc. All rights reserved.
UPMC for Life Complete Care (HMO D-SNP) members
Call us: 1-800-606-8648
TTY: 711
Oct. 1 – March 31:
Seven days a week from 8 a.m. to 8 p.m.
April 1 – Sept. 30:
Monday through Friday from 8 a.m. to 8 p.m.
UPMC for Life Complete Care prospective members
Call us: 1-844-575-8241
TTY: 711
Oct. 1 – March 31:
Seven days a week from 8 a.m. to 8 p.m.
April. 1 – July 31:
Monday through Friday from 8 a.m. to 8 p.m.
Aug. 1 – Sept. 30:
Monday through Friday from 8 a.m. to 8 p.m. Saturday from 9 a.m. to 3 p.m.
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Last Updated: 10/1/2025