Dual-eligible Medicare and Medicaid plans

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 wide covers a 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 be helpful 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 and UPMC Community HealthChoices. You can enroll in these plans if you are dually eligible for 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 (HMO D-SNP) 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 prescription copays. You also get additional benefits including additional dollars to buy over-the-counter (OTC) products, healthy foods, and household utilities. You’ll also get vision, dental, and hearing care, transportation services; unlimited gym memberships; and home-delivered meals.
• UPMC Community HealthChoices is a Medicaid plan that provides secondary coverage for most of your medical, prescription, 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.

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
• Pregnant, blind, disabled, age 65 or older, parent or caretaker of a dependent child, child under 21, or a woman with breast or cervical cancer

How to apply for Dual Medicare and Medicaid

Steps to apply for Dual Medicare and Medicaid:

1. Check eligibility. Make sure you meet the requirements for both Medicare and Medicaid. This includes age, disability status, income level, and residency.
2. Gather documentation. Collect important documents such as proof of income, identification, Social Security number, and medical records.
3. 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.
4. Apply for Medicaid. Apply for Medicaid through your state’s Medicaid office or online portal.
5. 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.
6. Coordinate benefits. After you have enrolled, check your benefits to make sure you are getting the most out of both programs. 

*UPMC for Life Complete Care benefits must be used before UPMC Community HealthChoices benefits can be used.

**All UPMC for Life Complete Care allowance amounts are based on the 2025 benefit year. Some benefit allowances are monthly or quarterly based. For more information about benefit allowances, call us toll-free at 1-844-575-8241 (TTY: 711).

***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 3, 2024
• Issue 2, 2024
• Issue 1, 2024

Learn more about the UPMC for Life Complete Care plans available in your area

Learn more about UPMC Community HealthChoices