Someone who has both Medicare and Medicaid is dually eligible. Medicare pays first for hospital and doctor care; Medicaid covers what Medicare leaves, including premiums, cost sharing, some prescriptions, transportation to appointments, and the long-term care Medicare does not pay for at all.

It is not a paperwork error and it is not rare. It is the normal situation for a person over 65 with a low income, and it has to be applied for, because only the Medicare half arrives on its own.

In New York: three levels get called dual eligibility. Full dual eligibility is Medicare plus full Medicaid, which reaches long-term care. QMB, at or below 138% of the federal poverty level, has Medicaid pay Medicare premiums plus deductibles, coinsurance and copays, and providers may not bill you for that cost sharing on covered services. QI, at or below 186%, pays the Part B premium.

New York applies no asset test to QMB or QI, unlike most states, and the state’s limits sit above the federal minimum after a 2023 expansion that also folded SLMB into the two-tier structure. Anyone told they had too much saved, or told so before 2023, should check again.

The Medicaid side is applied for at the local department of social services, not at NY State of Health, for anyone 65 or older.

Also called: dually eligible, Medicare and Medicaid together, QMB. Full guide: Having Medicare and Medicaid together in New York.

More in Glossary of health coverage and billing terms

  • Formulary — A formulary is a plan's list of covered drugs, sorted into tiers that set your cost. What on-formulary means, how exceptions work, and New York's NYRx list.
  • Prior authorization — Prior authorization is a plan's approval before it pays for care. Who asks for it, what a denial says, where the deadlines are, and New York's appeal route.
  • Explanation of benefits (EOB) — An explanation of benefits (EOB) is your plan's record of a claim, not a bill. How to read each line, which one a bill must match, and what a denial means.
  • Managed Long Term Care (MLTC) — The plan that authorizes and pays for long-term home care in New York. It is the payer, not the care itself.
  • Fair hearing — The state's review of a decision about your Medicaid, with two different deadlines that people routinely confuse.

This page explains how the system works. It is not medical advice. More.