What Are the Primary Medicaid Eligibility Pathways for Dual-Eligible Individuals?
Key Pathways to Full Medicaid for Dual-Eligible Individuals
To qualify for full Medicaid benefits, Medicare beneficiaries must meet the eligibility criteria for one of the Medicaid eligibility pathways. Among the eligibility pathways that are most common for dual-eligible individuals, some pathways enroll mostly people without Medicare while dual-eligible individuals comprise most enrollees in other pathways.
Supplemental Security Income: States generally must provide Medicaid to people who receive SSI, except in the 8 Section “209(b)” states for which eligibility is not directly tied to SSI. The 209(b) states (Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, and Virginia) use financial or functional eligibility criteria that are more restrictive than the federal SSI rules, but no more restrictive than the rules the state had in place in 1972 when SSI was established. In 2021, the 4.6 million dual-eligible individuals enrolled through SSI represented almost half of the 9.6 million total Medicaid enrollees eligible through this pathway.
Poverty Related Coverage: States may choose to offer coverage to seniors and people with disabilities who have low incomes. In 2021, the 1.3 million dual-eligible individuals enrolled through this pathway comprised two thirds of the 1.9 Medicaid enrollees who were enrolled through pathways for low-income seniors and people with disabilities.
Medically Needy Coverage: States may use medically needy pathways to extend coverage to people who would be eligible through another pathway but have income or assets that exceed the limit for that pathway. People may qualify through a medically needy pathway if their income is higher than permitted under a different pathway but lower than the medically needy limit, or if they “spend down” to the medically needy limit by deducting health care expenses from their income. For people who spend down to eligibility, states select a budget period between one and six months during which the individual must incur enough expenses to decrease their income below the limit. In 2021, there were 0.9 million dual-eligible individuals, 23% of all Medicaid enrollees eligible through medically needy pathways.
Buy In Programs: Medicaid buy in programs allow people with disabilities to retain Medicaid coverage when their income increases above eligibility levels on account of their own employment. In 2022, the median income limit for the buy in was 250% FPL and the median asset limit was $10,000 for an individual. Although fewer than 0.2 million full-benefit dual-eligible individuals enrolled in the buy in programs in 2021, dual-eligible individuals comprised nearly 80% of all people participating in such programs that year.
Long-Term Services and Supports: States have many options to cover people who use LTSS through Medicaid. Dual-eligible individuals comprise 83% of Medicaid enrollees that are enrolled through the pathways using a special income rule for people who require an institutional level of care and other expansions specifically for people using home- and community-based services (1 million out of 1.2 million). The one LTSS-related pathway that enrolls few duals is the Katie Beckett option, which covers children up to age 19 who require an institutional level of care but are living at home. Nearly 50,000 children were enrolled in 2021, roughly 100 of whom were dual-eligible individuals.
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