dual eligibility medicare medicaid

Dual Eligibility Medicare Medicaid | Dually Eligible Individuals

The person who is dually enrolled in both insurance Medicare and Medicaid, also known as dually eligible individuals or dual eligibility medicare-medicaid, for dually eligibility need to person fall into several eligibility categories. These people may either be enrolled 1st in Medicare and then qualify for Medicaid eligibility, or vice versa.

Dually eligible individuals are enrolled in Medicare Part A and/or Part B and are also enrolled in full-benefit Medicaid and/or the Medicare Savings Programs (MSPs) administered by each individual state. MSPs assist low income Medicare beneficiaries with some or all of their Medicare Parts A and B expenses.

Medicare Coverage

Medicare coverage has four parts:

  • Medicare Part A– Its is also known as Medicare Hospital Insurance, this is for Hospital claims, it helps cover inpatient care in hospitals, like SNF-Skilled Nursing Facility, home health care, hospice, etc. Most individuals qualify for premium-free Part A. However, person  who lack a sufficient work history can pay a monthly basis premium to enroll in Part A. The MSP may pay the premium for certain individuals who must pay a premium to enroll in Part A. For Medicare part A applicants must live in the U.S. and either be a U.S citizen or a Legal Permanent Resident who has lived in the U.S. continuously for five years.
  • Medicare Part B– It is also known as physician or professional claims insurance or Supplemental Medical Insurance, it helps cover doctor and other health care providers’ services, outpatient care, home health care, DME- Durable Medical Equipment, and some preventive care services. All individuals pay a monthly Part B premium except for those enrolled in a MSP that pays their Part B premium.
  • Medicare Part C –  This Medicare part C also known as  Medicare Advantage plan which provides Part A and Part B benefits to people with Medicare who enroll in these plans. Medicare Advantage plan is offered by private companies as well that contract with Medicare to provide Part A and Part B benefits, and in most cases, Part D. Dually eligible beneficiaries may also get help with Medicare Part C costs.

o  Plans that integrate Medicare coverage with Medicaid include Programs of All- inclusive Care for the Elderly (PACE), Medicare-Medicaid Plans (MMPs), Fully Integrated Dual Eligible Special Needs Plans, and Highly Integrated Dual Eligible Special Needs Plans.

  • Part D (outpatient prescription drugs) provides coverage of prescription drug costs through private plans. Beneficiaries who qualify for Medicaid or an MSP in a state automatically qualify for Extra Help (also known as the Low-Income Subsidy program) to help pay for the costs — monthly premiums, annual deductibles, and prescription copayments — related to Medicare Part D.

Medicaid Coverage

Medicaid provides health coverage to thousands of American citizens, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is a state based program and funded jointly by states and the federal government. Medicaid has broad national guidelines established by federal government, regulations, and policies, and  each state has the flexibility to:

  • Establish its own eligibility criteria and standards
  • Determine the type, duration, , amount and scope of services
  • Set the rate of payment for services; and
  • Administer its own program.

Medicare and Medicaid cover many of the same services. All providers, including Medicare providers, must enroll in their Medicaid system for Medicaid claims , payment  and processing of Medicare cost-sharing. Providers should contact the state Medicaid agency for additional information regarding Medicaid provider enrollment.

Medicare pays 1st for Medicare covered services that are also covered by Medicaid because Medicaid is generally the payer of last resort. Medicaid may cover care that Medicare does not cover (such as a variety of longterm services and supports).

Table 1 – Eligibility Categories and Assistance with Medicare Part A and Part B Costs

This section summarizes the eligibility categories for dually eligible individuals, including the degree to which individuals in each category receive assistance with Medicare Parts A and B premiums and cost sharing. Each eligibility category is mutually exclusive.

CategoryMonthly Income as of 2021*Assets as of 2021*Covers Part A premium
(when applicable)		Covers Part B premiumCovers Parts A & B cost sharingFull Medicaid coverage**
QMB OnlyIndividual: $1,094;Individual: $7970XXX***
Married Couple: $1472Married Couple: $11960
QMB PlusIndividual: $1,094;Individual: $7970XXX***X
Married Couple: $1472Married Couple: $11960
SLMB OnlyIndividual: $1,308Individual: $7970X
Married Couple: $1762Married Couple: $11960
SLMB PlusIndividual: $1,308Individual: $7970XVariies State
Married Couple: $1762Married Couple: $11960****
QIIndividual: $1469Individual: $7970X
Married Couple: $1980Married Couple: $11960
QDWIIndividual: $4,379Individual: $4,000X
Married Couple: $5892Married Couple: $6000
Full Benefit Medicaid Only **Determined by stateDetermined by stateVaries by state****Varies by state
*****		X
Dual Eligibility Medicare Medicaid

Notes-

*The limits on income and resources of the MSPs are announced each year through CMS. Centers for Medicare & Medicaid Services (CMS). The QDWI income limit also includes an earned-income disregarding $65. For asset limits, the calculation of QMBs, SLMBs, and QIs is three times the SSI limit for resources, and is which is adjusted annually to reflect increases of the Consumer Price Index (effective January 1st 2010,). States are able to raise the threshold for income and resource standards by utilizing the provisions under the section 1902(r)(2) (r)(2) of the Social Security Act, which generally allows states’ Medicaid agencies to not count the income and resources considered to be part of standards for financial eligibility. Some states have benefited from the power of subsection 1902(r)(2) (r)(2) of the Act to remove any requirements for resources for MSP groups.

** “Full-benefit” Medicaid coverage generally is a reference to the provision of coverage for a variety of goods and services in addition to coverage for Medicare cost-sharing and premiums which certain people have the right to receive when they fall within specific eligibility categories that are part of the State Medicaid Plan (state plan). People who qualify as QMB or SLMB “plus” get benefits that are full Medicaid as well as Medicare cost-sharing as well as premiums coverage. People who are eligible for full-benefit Medicaid only have the right to Medicare Part A and/or are enrolled in Part B and can be eligible in full benefits Medicaid benefits but not those who are part of the QMB or SLMB programs.

*** While people participating in QMB don’t have to have to pay Medicare coinsurance, deductibles, and copays. However, QMB members might be required to pay a modest Medicaid contribution for specific Medicaid-inclusive services.

**** State pay Part B costs in the event that they have all Medicaid categories within their Part B buy-in group.

***** The beneficiary is not required to pay more than what is allowed by the state program for services that are covered by both Medicare as well as Medicaid. Additionally all Medicare provider (regardless whether they participate in Medicaid enrollment) must accept the Medicare-approved amount as a full payment for services provided by Part B in the case of dual beneficiaries.

Qualified Medicare Beneficiaries (QMBs) without other Medicaid

QMB The only ones who are called QMB “partial benefit” are enrollees within Medicare Part A with a monthly income of that is up to 100 percent that of federal poverty limit (FPL) and have resources that are not more than 3 times the limit of the supplementary security income (SSI) eligibility. They are eligible for adjustments for inflation. They aren’t otherwise qualified for full benefit Medicaid coverage. Medicaid covers their Medicare Part A premiums, in the event that they have any, as well as Medicare Part B premiums. Medicare providers cannot charge QMBs with Medicare Parts A and B cost sharing amounts which include coinsurance, deductibles, and copays.

Providers may charge Medicaid programmes for the sum, however states are able to decrease or eliminate

Stop the state’s Medicare cost-sharing payments through the adoption of guidelines that limit the amount of payments to the lower of

(a) (a) the Medicare cost sharing amount (b) the Medicare cost sharing amount, (b) that is the amount between Medicarepayment as well as the Medicaid cost for the service.

QMBs with full–benefit Medicaid (QMB Plus)

QMB Plus meet the QMB-related eligibility requirements as described above, as well as the eligibility requirements of a separate “categorical” eligibility group that is covered by the state Medicaid program. QMB “Plus” people have access to the entire array of Medicaid benefits that are available to the distinct group of eligible individuals in which they qualify. Medicaid covers the Medicare Part A premiums, in the event that they have any, as well as Medicare Part B premiums. Medicare providers cannot charge QMBs in respect of Medicare Parts A and B cost sharing such as coinsurance, deductibles, and copays. Doctors may invoice Medicaid program for such costs However, states can cut down or eliminate Medicare cost sharing payment through the adoption of guidelines that limit payments to the lower amount of (a) that of the Medicare cost-sharing amount as well as (b) that difference of and the Medicare payments and Medicaid cost for the service. QMBs who have full-benefit Medicaid are not required to pay more than Medicaid coinsurance (if applicable) for the services covered under the state’s plan (i.e. services that is provided by the Medicaid provider, and which is covered by either (1) Medicare and Medicaid or (2) Medicaid, but not Medicare or Medicaid, covers).

Specialized low-income Medicare Beneficiaries (SLMBs) without any other Medicaid (SLMB-Only – also referred to by the name of SLMB “partial-benefit”)are enrolling in Part A of Medicare and earn between 100 to 120 percent of FPL and have resources that do not exceed three times the amount for Supplemental Security Income (SSI) eligibility. They are eligible for adjustments to account for inflation. Medicaid is the only source of Medicare Part B premiums for the SLMB group.

Specified Low-Income Medicare Beneficiaries (SLMBs) with full-benefit Medicaid (SLMB Plus

SLMB Plus also called SLMB “full benefits” satisfy the SLMB-related eligibility requirements mentioned above, as well as the eligibility requirements for a distinct “categorical” eligibility group that is covered by the states Medicaid plan. In addition to insurance coverage to pay Medicare Part B premiums, the SLMB Plus beneficiaries receive full benefits Medicaid benefits (i.e. the entire package of benefits that are provided to the group that they are eligible for). The SLMBs who have full-benefit Medicaid are only required to pay their Medicaid coinsurance (if applicable) for the services covered under the plan of state (i.e. the care is provided by an Medicaid provider, and which is covered by either (1) Medicare and Medicaid or (2) Medicaid, but not Medicare will cover). The SLMBs are required to pay Medicare cost-sharing for Medicare-covered healthcare that is not included in the state plan, unless the state elects to pay the expenses.

Qualifying Individuals -QI

QI is part of Part A and earns a salary at or above 120%, but not more than 135 percent of the FPL, and resources that do NOT exceed the three-fold limit for additional security income (SSI) eligibility. This includes adjustments to account for inflation. QIs are not eligible for an individual eligibility group by the state Medicaid program. QIs are covered of Their Medicare Part B premiums, in the event that their state Medicaid programs are able to pay for it. The federal government distributes annual allocations to states to pay for Part B premiums.

Qualified Disabled and Working Individuals (QDWI)

QDWI also known as QDWI “partial benefit”) became eligible for premium-free Part A by virtue of qualifying for Social Security disability insurance, but lost those benefits, and consequently Premium-free Medicare Part A, because they returned to work. QDWIs have income that does not exceed 200% of the FPL, resources that do not exceed two times the SSI resource standard, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only.

Full-benefit Medicaid Only:

beneficiaries are entitled to Medicare Part A and or enrolled in Medicare Part B, and qualify for full Medicaid benefits, but not the QMB or SLMB programs. Full benefits Medicaid coverage is a bundle of services, which extends beyond the coverage of Medicare costs and premiums, which some individuals have access to in the event they are eligible under group eligibility under the states Medicaid program. Certain coverage categories are those that states typically have to be able to cover (for instance the people who receive supplemental security income (SSI) recipients) while others are ones that states can choose to provide (for instance for example, for instance, the “special levels of income” group for individuals who are institutionalized as well as homeand community -based (HCBS) participants in programs and “medically needy” people). Some of the services included in the Medicaid benefits package are services that Medicare is not able to include, like certain long-term support and services (LTSS) as well as transportation, behavioral health as well as vision and transportation services. Medicaid benefits differ by state. The full-benefit Medicaid beneficiary is not required to pay less than Medicaid coinsurance (if applicable) for services that are covered by the plan of state (i.e. services that is provided by an Medicaid provider and is provided by a Medicaid:

(1) Medicaid and Medicare or

(2) Medicaid, but not Medicare and Medicare cover). They are required to pay Medicare cost-sharing for Medicare-covered services not covered by the state’s plan, unless the state opts to pay for these expenses.

Reference Document:

Dually Eligible Individuals- Dual Eligibility Medicare Medicaid

Physician Fee Schedule Medicare for Calendar Year 2023

Best Health Insurance Companies in Arizona

Blue Cross Blue Shield Medicaid

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  • NSingh (MBA, RCM Expert)

    The author and contributor of this blog "NSingh" is working in Medical Billing and Coding since 2010. He is MBA in marketing and Having vaste experience in different scopes of Medical Billing and Coding as AR-Follow-up, Payment Posting, Charge posting, Coding, etc.

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