Dual Eligible Medicare Medicaid
Managing health coverage can be complicated, but for those who qualify, being dual eligible for Medicare and Medicaid simplifies it.
This vital coverage mesh can offer eligible individuals expansive healthcare at minimal cost.
This guide outlines who qualifies for dual eligible Medicare Medicaid, elucidates the myriad benefits, and gives actionable insights into utilizing these two crucial programs to secure your health needs.
Key Takeaways
- Dual eligibility refers to individuals qualifying for both Medicare and Medicaid, typically based on age or disability combined with low income, providing them with comprehensive healthcare coverage and financial assistance for premiums and cost-sharing.
- Medicare Savings Programs, such as QMB, SLMB, and QI, are essential supplements for dual eligibles, offering assistance with Medicare premiums and out-of-pocket costs, with eligibility criteria including income and resource limits that vary annually.
- Care coordination between Medicare and Medicaid for dual-eligible beneficiaries is crucial to achieve comprehensive healthcare coverage, with various state strategies in place to manage this complex relationship, involving managed care plans like D-SNPs and LTSS for a wide range of medical and support services.
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Dual Eligibility: Medicare and Medicaid Explained
Individuals enrolled in both Medicare and Medicaid programs due to their age, disability, and low income are referred to as dual-eligible.
As of 2019, there were 12.2 million dual eligible beneficiaries, often with low incomes and very modest savings, indicating a significant need for financial assistance from both Medicare and Medicaid.
Being dual-eligible means you carry primary health insurance coverage through Medicare and receive supplemental assistance from the state Medicaid program. This combination of programs provides comprehensive healthcare coverage and acts as a more reliable safety net for those in need.
What is Dual Eligibility?
To qualify as a dual eligible beneficiary, one must be qualified for Medicare, generally being 65 or older or under 65 with certain disabilities, and also meet the low-income criteria to be eligible for Medicaid. It’s a delicate balance of requirements, but once met, the benefits can be life-changing.
A person achieves dual-eligible beneficiary status by enrolling in Medicare Part A and/or Part B and participating in Medicaid, either as a full-benefits recipient or through Medicare Savings Programs.
It’s a comprehensive approach to healthcare coverage, ensuring that those who qualify have access to a wide range of critical services.
Why is Dual Eligibility Important?
By merging the benefits of Medicare, primarily covering acute and post-acute care services, with Medicaid, dual-eligible individuals gain comprehensive healthcare coverage. This collaboration of programs results in a more robust safety net for those who need it most.
Dual-eligible beneficiaries are financially supported by Medicaid in terms of assistance with Medicare premiums and cost-sharing. Additionally, Medicaid provides coverage for some healthcare services not included in Medicare, offering a broader range of care options to dual eligibles.
Long-term services and supports (LTSS), essential for many beneficiaries with chronic conditions or disabilities, are also made available through Medicaid for those who are dual-eligible.
Medicare Savings Programs: Helping You Pay for Medicare Premiums
Despite not covering the full spectrum of Medicaid benefits, Medicare Savings Programs are designed to assist partial-benefit dual eligibles with Medicare premiums and cost-sharing. These programs are pivotal in ensuring that dual eligibles, categorized into ‘partial duals’ and ‘full duals,’ are supported in their healthcare needs.
States may have a ‘spend down’ program that enables individuals whose incomes are too high for standard Medicaid eligibility to qualify by using their medical expenses, including Medicare premiums, as a method to lower their countable income and meet Medicaid requirements. These programs serve as an essential bridge in providing comprehensive healthcare coverage.
Qualified Medicare Beneficiary (QMB) Program
The QMB Program acts as a significant support system for dual eligibles. It covers:
- Medicare Part A and Part B premiums
- Deductibles
- Copayments
- Coinsurance for services and items approved by Medicare
This helps alleviate the financial burden of healthcare costs for dual eligibles.
For individual eligibility in 2024, the QMB Program requires a monthly income limit of $1,275 and a resource limit of $9,430; for a married couple, resource limits are set at $13,630.
Qualified Medicare Beneficiaries (QMBs) are safeguarded by balance billing protection, preventing providers from charging more than the combined payments of Medicare and Medicaid.
Specified Low-Income Medicare Beneficiary (SLMB) Program
The SLMB Program serves as a crucial support for individuals enrolled in both Part A and Part B of Medicare. Individuals with income between 100-120% of the Federal Poverty Level and resources under $9,090 may qualify for this program.
The monthly income limit for an individual to qualify for the SLMB Program in 2024 is $1,526, and the resource limit is $9,430. The program assists with the Medicare Part B premium, which is $174.70 in 2024.
These income and resource limits are subject to change annually, so it’s important to stay updated on the most current requirements on the Medicare Savings Programs page.
Qualifying Individual (QI) Program
The Qualifying Individual (QI) Program offers additional support within the Medicare Savings Programs. It provides assistance to pay Medicare Part B premiums for eligible individuals who are not qualified for Medicaid.
To be eligible for the QI Program, an individual’s income must be between 120-135% of the Federal Poverty Level, with the 2024 limits for monthly income at $1,715 for individuals and $1,426 for a married couple after a $20 general income disregard. The program steps in to aid with the payment of Part B premiums for eligible individuals who have both Part A and Part B.
Applications for QI benefits must be submitted every year and are processed on a first-come, first-served basis, with priority given to people who received QI benefits the previous year.
How Dual Eligible Beneficiaries Receive Services: Coordination between Medicare and Medicaid
Although complex, the coordination between Medicare and Medicaid for dual-eligible beneficiaries is vital for securing comprehensive healthcare coverage. State Medicaid programs typically employ a variety of strategies, including requirements for coordinated care and payment of Medicare cost-sharing within managed care plans.
Programs like Medicare-Medicaid Plans (MMPs) are examples of the Financial Alignment Initiative where a unified health plan manages all Medicare and Medicaid benefits. These initiatives, along with others like Medicaid managed care, PACE programs, and D-SNPs, are being explored by policymakers to advance Medicare-Medicaid coordination.
Payment Hierarchy: Who Pays First?
In the realm of dual eligibility, it’s vital to understand which program plays the role of the primary payer. Medicare serves as the primary payer for services covered by Medicare, while Medicaid provides supplemental coverage.
Dual-eligible beneficiaries are automatically enrolled in a Medicare drug plan for prescription coverage; this is separate from Medicaid drug coverage.
For non-QMB dual eligibles, Medicaid agencies are responsible for paying the Medicaid rate for Medicaid-covered services received from Medicaid providers.
In certain states, managed care plans are employed to facilitate the coordination of benefits for dual-eligible individuals.
Coordinating Care: Navigating the Health Care System
Dual-eligible individuals often encounter difficulties with care coordination due to the separate eligibility requirements, benefits, and rules of Medicare and Medicaid, leading to a fragmented healthcare system.
To combat this, nearly all states have developed strategies for care coordination for dual eligibles, with Medicaid-managed care plans playing a significant role in delivering Medicaid benefits and covering Medicare cost-sharing.
An integrated approach to care is needed to improve health delivery for dually eligible beneficiaries, who account for a significant portion of Medicare and Medicaid spending, requiring accountability for quality and costs across both programs and policy support.
Enhanced management of care transitions, such as moving from hospital to home, is crucial for dual-eligible beneficiaries to ensure continuity of care and prevent health complications.
Dual Eligible Special Needs Plans (D-SNPs): Tailored Coverage for Dual Eligibles
Dual Eligible Special Needs Plans (D-SNPs) are specialized Medicare Advantage plans, optional for individuals eligible for both Medicare and Medicaid.
Established by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and made permanent by the Bipartisan Budget Act of 2018, they play a critical role in providing tailored coverage for dual eligibles.
D-SNPs are operational in 45 states and the District of Columbia, with approximately 3.8 million dually eligible beneficiaries enrolled as of February 2022.
States demonstrate a vested interest in D-SNPs and are pursuing integrated care models including the Financial Alignment Initiative for dual-eligible beneficiaries to improve care and reduce costs.
What are D-SNPs?
D-SNPs are a type of Medicare Advantage (Part C) plan designed specifically for those who qualify for both Medicare and Medicaid, with the goal of managing care and coordinating multiple coverages.
To qualify for a D-SNP, an individual must be enrolled in Medicare Part A and/or Part B and also receive Medicaid benefits or assistance with Medicare premiums or cost-sharing.
These plans, known as Medicaid plan, provide Medicare-covered services and may also coordinate or cover Medicaid benefits as per state requirements.
They are the most common type of dual-eligible plan, integrating benefits across both Medicare and Medicaid programs. In addition to standard Medicare services, D-SNPs offer supplemental benefits that are usually covered by Medicaid, such as:
- Dental care
- Vision
- Hearing aids
- Non-emergency transportation
Benefits of Enrolling in a D-SNP
D-SNPs offer a wealth of benefits, including:
- Improved care integration mandated by federal requirements and enhanced through state-specific contracts
- Additional benefits not typically covered by original Medicare or Medicaid, such as gym memberships, food allowances, over-the-counter products, and transportation
- Better health outcomes and patient satisfaction
These benefits contribute to the overall effectiveness of D-SNPs.
Moreover, members of D-SNPs tend to incur little to no out-of-pocket costs for healthcare services, contributing to financial relief and decreased overall healthcare expenditures for dual-eligible individuals.
This is a testament to the significant role D-SNPs play in ensuring the welfare of dual eligibles.
Long-Term Services and Supports (LTSS) for Dual Eligible Beneficiaries
Full-benefit dual eligibles have access to the complete range of full Medicaid benefits, encompassing long-term services and supports not covered by Medicare. These Medicare benefits, along with Medicaid services, are critical in providing comprehensive healthcare coverage to those who need it most.
Full dual eligibles have access to various healthcare services, particularly LTSS, which are not covered by Medicare, unlike partial duals who receive assistance with Medicare premiums and cost-sharing.
Fully integrated dual-eligible special needs plans (FIDE SNPs) and highly integrated dual-eligible special needs plans (HIDE SNPs) offer dual eligibles a complete integration of care, including LTSS.
Home and Community-Based Services (HCBS)
The Program of All-Inclusive Care for the Elderly (PACE) is an HCBS option that provides comprehensive medical and social services to dual-eligible individuals who meet specific criteria, blending Medicare and Medicaid services for these beneficiaries.
Dual-eligible beneficiaries maintain their Medicaid benefits when enrolling in a D-SNP, including access to personal care services, ensuring continuity of care.
HCBS options like Nevada D-SNPs enhance the coverage for dually eligible beneficiaries by incorporating additional services such as:
- Dental care
- Vision services
- Personal emergency response systems
- Meal delivery following hospital stays
These services play a crucial role in providing a holistic care approach to dual eligibles.
Institutional Care: Nursing Homes and Intermediate Care Facilities
Apart from home and community-based services, institutional care plays a significant role in providing long-term care for dual eligibles. Services like nursing homes and intermediate care facilities offer essential support for those who require more intensive care.
These facilities provide an array of services, ensuring that dual eligibles receive the care they need. Some of the services provided by institutional care facilities include:
- Medical care
- Assistance with daily activities
- Social and recreational activities
- Mental health support
- Rehabilitation services
These services are designed to ensure the well-being and comfort of dual eligibles.
Financial Incentives and Cost Sharing for Dual Eligibles
Depending on the dual eligibility category, various Medicare Savings Programs serve as a safety net for beneficiaries by providing Medicare coverage and covering costs such as:
- Medicare Part A and B premiums
- deductibles
- coinsurance
- copayments
These financial incentives and cost-sharing measures significantly reduce the financial burden of healthcare for dual eligibles.
However, the scope of assistance each beneficiary receives varies by category, affecting income qualifications, covered benefits, and restrictions. Understanding these variations is crucial in making the most of the dual eligibility benefits.
Premium Assistance: How Medicaid Helps Pay Medicare Premiums
The majority of full-benefit dual-eligible individuals benefit from the premium and cost-sharing assistance offered by the Medicare Savings Program. Medicare pays the monthly premiums for Medicare Part B for individuals who qualify for full Medicaid coverage, while Medicaid pays for additional services.
To be eligible for Medicaid’s premium assistance, individuals must meet their state’s income and resource limits and qualify as full-benefit dual eligible. This assistance plays a vital role in ensuring comprehensive healthcare coverage for dual eligibles.
Reduced Out-of-Pocket Costs: Copayments, Deductibles, and Coinsurance
Beneficiaries qualified for the QMB Program are not billed for Medicare-covered services and items and may only pay up to $11.20 for each drug covered by their Medicare drug plan in 2024.
QI beneficiaries will also pay no more than $11.20 for each drug covered by their Medicare drug plan in 2024, reducing their out-of-pocket prescription costs.
Dual-eligible beneficiaries sometimes face copayments after an initial coverage period when using Medicare Advantage plans for rehabilitation facilities.
To avoid high copays and secure a full 100 days of coverage, dual-eligible beneficiaries can benefit from switching from a Medicare Advantage plan back to Traditional Medicare during their stay in a facility.
Enrolling in a Medicare Advantage Plan
You can enroll in a Medicare Advantage Plan during your Initial Enrollment Period or a Special Enrollment Period, based on your eligibility. To enroll, you can contact 800-MEDICARE (800-633-4227) or enroll directly with the private insurer.
Medicare requires that individuals enroll, disenroll, or make changes to their Medicare Advantage plan during pre-determined enrollment periods.
The Initial Enrollment Period for Medicare Advantage Plans is seven months in duration, including three months before, during, and after your 65th birthday.
If you miss this opportunity, you may be eligible for a Special Enrollment Period under certain circumstances, such as changes in residence, loss of employer coverage, or eligibility for other government programs.
It’s important to refer to official sources for a full list of qualifying circumstances and to complete the application process within the specified timeframe.
Initial Enrollment Period
The Initial Enrollment Period is a crucial time to enroll in a Medicare Advantage Plan. This 7-month window typically begins 3 months prior to your 65th birthday and ends either on the last day of your Part B initial enrollment period or the last day of the month after your 65th birthday.
During this period, you have the opportunity to enroll in a Medicare Advantage Plan with drug coverage or a Medicare drug plan, ensuring you have the coverage you need as you enter your golden years.
Special Enrollment Periods
Special Enrollment Periods allow you to enroll in a Medicare Advantage Plan outside of the Initial Enrollment Period under certain circumstances. If you experience certain life events or exceptional circumstances, such as losing your current health coverage, moving to a new area, or qualifying for Extra Help, you may be eligible for a Special Enrollment Period.
These periods typically last for two months, providing you with an opportunity to enroll in a Medicare Advantage Plan tailored to your needs and circumstances.
Summary
Understanding dual eligibility and its benefits is crucial for those who qualify for both Medicare and Medicaid.
From comprehensive healthcare coverage to reduced out-of-pocket costs, dual eligibility ensures that those who need it the most have access to the care they deserve.
Programs like Medicare Savings Programs, D-SNPs, and LTSS provide a safety net, easing the financial burden of healthcare and ensuring a more integrated and coordinated care approach.
Navigating the complexities of dual eligibility might be challenging, but the benefits it offers are worth it.
Frequently Asked Questions
→ Why do people have both Medicare and Medicaid?
People have both Medicare and Medicaid because they may be in relatively good health but have limited financial resources, or they may have spent their income and wealth on health or long-term care costs.
→ What plan provides both Medicare and Medicaid coverage to certain eligible beneficiaries?
Medicare Advantage dual eligible special needs plans (D-SNPs) provide both Medicare and Medicaid coverage to certain eligible beneficiaries by coordinating Medicaid benefits for their enrollees.
→ When the patient is covered by both Medicare and Medicaid what would be the order of reimbursement?
When a patient is covered by both Medicare and Medicaid, Medicare will pay first for the services received, and Medicaid will pay last, after Medicare and any other health insurance. This means that Medicaid is the payer of last resort, always paying last.
→ What is dual eligible Medicare-Medicaid in Florida?
In Florida, dual eligibility for Medicare and Medicaid means individuals can be enrolled in both Medicare and full Medicaid or in Medicare and one of Medicaid’s Medicare Savings Programs, which helps pay for Medicare premiums. This provides primary and supplemental health insurance coverage for eligible individuals.
→ Medicaid what is?
Medicaid is a joint federal and state program that provides health coverage to over 72.5 million Americans with disabilities, low-income families, children, pregnant women, parents, and seniors. It is designed to assist people with limited income and resources in covering medical costs.
ZRN Health & Financial Services, LLC, a Texas limited liability company
Russell Noga is the CEO of ZRN Health & Financial Services, and head content editor of several Medicare insurance online publications. He has over 15 years of experience as a licensed Medicare insurance broker helping Medicare beneficiaries learn about Medicare, Medicare Advantage Plans, Medigap insurance, and Medicare Part D prescription drug plans.