Medicare and Medicaid | Dual Eligibles - HealthPocket

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Medicare and Medicaid | Dual Eligibles


When someone is simultaneously enrolled in the Medicare and Medicaid programs, they have some benefits and options not available to other enrollees:

  • Reduced deductibles and copays for drugs through the Extra Help program
  • The ability to change drug plans or health plans throughout the year

Approximately 10 million people are enrolled in both Medicare and Medicaid. That’s about one-out-of-five Medicare enrollees.

What is Dual Eligible?

Dual eligible is a term that describes an individual that qualifies for both Medicare and Medicaid. A dual eligible may qualify for Extra Help from Medicare to help pay for the cost of their Medicare Prescription Drug Plan. Medicare is the largest social insurance program offered by the U.S. Federal government since 1966, serving over 48 million Americans, the vast majority of which are over the age of 65. Part A covers hospital insurance and is generally already paid for through paycheck deductions during the 10 or more years you or your spouse were a "qualified wage earner". However Part B, which covers medical insurance, is paid for by most Medicare recipients via a monthly premium once they turn 65. If you are still working you should check with your employer to see if your current employer-sponsored health insurance coverage works with Medicare.

Medicaid is a social health care program created in the 1960s alongside Medicare that offers funding for medical and health-related services to low-income families and individuals. CHIP (Children’s Health Insurance Program) was created in 1997 to help cover uninsured children in families with incomes too high to qualify for Medicaid but incomes too low to afford healthcare coverage. Medicaid and CHIP currently provide healthcare coverage to almost 72.5 million Americans1. Medicaid is jointly funded by both the Federal government and by state governments, with states managing the program. All recipients must be U.S. citizens or legal permanent residents and, unlike Medicare, there is no general age requirement.

Dual Eligible Medicare Beneficiary Groups

Dual eligibles with limited benefits include Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), Qualifying Individuals (QI), & Qualified Disabled Working Individuals (QDQI). In contrast, Full Benefit Dual Eligibles (FBDE) are those who qualify for full Medicaid benefits.3 The following is a brief description of each of the seven dual eligible beneficiary groups4:

  • Qualified Medicare Beneficiary without other Medicaid (QMB only): an individual entitled to Medicare Part A, with an income of 100% Federal poverty level or less and resources that don’t exceed 3 times the limit for Supplementary Security Income (SSI) eligibility. QMBs are eligible for Medicaid payments for Part A & Part B premiums and Medicare deductibles and coinsurance for Medicare services.
  • QMB+: an individual who meets standards for QMB eligibility but also meets the criteria for full Medicaid benefits. QMB+s are eligible for Medicaid payment for Part A & Part B premiums, Medicare deductibles and coinsurance for Medicare services. Criteria for full Medicaid benefits are often met by meeting "Medically Needy" standards or by spending excess income in order to reach the Medically Needy level.
  • Specified Low-Income Medicare Beneficiary without other Medicaid (SLMB only): an individual entitled to Medicare Part A with an income between 100% and 120% Federal poverty level (higher than 100% FPL but less than 120% FPL) and resources that don’t exceed 3 times the SSI limit, and who is not otherwise eligible for Medicaid. SLMB are eligible for Medicaid payment of the Medicare Part B premium only and they don’t qualify for any additional Medicaid benefits.
  • SLMB+: an individual who meets the standards for SLMB eligibility but also meets the criteria for full Medicaid benefits. Medicaid pays for their Part B premium and like QMB+ criteria for full Medicaid benefits are often met by meeting "Medically Needy" standards or by spending excess income in order to meet the Medically Needy level.
  • Qualifying Individual (QI): an individual entitled to Medicare Part A with an income at least 120% Federal poverty level but less than 135% Federal poverty level and resources that don’t exceed 3 times the SSI limit, and who is not otherwise eligible for Medicaid. QIs are eligible for Medicaid payments for Part B premiums.
  • Qualifying Disabled and Working Individual (QDWI): an individual who lost Medicare Part A benefits due to returning to the workforce. QDWIs are eligible to enroll in and purchase Medicare Part A but the individual’s income must not be greater than 200% Federal poverty level and resources must not exceed twice the SSI limit. QDWIs are eligible for Medicaid payment for Part A premium.
  • Other full benefit dual eligible (FBDE): an individual who does not meet income or resource criteria for QMB or SLMB but is eligible for Medicaid based on their Medically Needy status, special income levels for individuals in an institution, or home and community-based waivers.

The following table illustrates the dual eligible standards for 2014. Income is represented by monthly amounts, not annual:

2017 Dual Eligible Standards2

Qualified Medicare Beneficiary (QMB)Specified Low-Income Medicare Beneficiary (SLMB)Qualifying Individuals (QI)Qualified Disabled Working Individuals (QDWI)
IncomeSingleCoupleSingleCoupleSingleCoupleSingleCouple
All (except AK & HI) + DC$1,025$1,374$1,226$1,644$1,377$1,847$4,105$5,499
Alaska$1,275$1,711$1,526$2,049$1,715$2,303$5,105$6,849
Hawaii$1,175$1,576$1,406$1,887$1,580$2,121$4,705$6,309
Resources$7,390$11,090$7,390$11,090$7,390$11,090$4,000$6,000

Dual eligibles can qualify for special plans such as Dual Eligible Special Needs Plans (D-SNPs). Dual eligibles with a special needs plan also qualify for a special enrollment period and are able to switch their plans at the beginning of each month. There are five categories of D-SNPs5:

  • All-Dual D-SNPs – enrollment limited to beneficiaries eligible for Medicare Advantage and who are entitled to medical assistance under Title XIX of the Social Security Act. All-Dual D-SNPs must enroll all categories of dual eligibles, including those with comprehensive Medicaid benefits as well as those with more limited cost sharing.
  • Full-Benefit D-SNPs – enrollment limited to individuals eligible for 1) Full Medicaid benefits for the month under any eligibility category or 2) Medical assistance for any month if the individual was eligible for assistance in any part of the month.
  • Medicare Zero Cost Sharing – enrollment limited to QMBs and QMB+s. QMB-only individuals are not entitled to full Medicaid benefits and thus may have to participate in Medicaid cost sharing.
  • Dual Eligible Subset – A Medicare Advantage organization that offers D-SNPs may exclude certain groups of dual eligibles. CMS reviews and approves requests for coverage of dual eligible subsets.
  • Dual Eligible Subset – Medicare Zero Cost Sharing – A dual eligible subset that does not include cost-sharing.

Extra Help Implications for Medicare Part C and Part D

Dual eligibles with Extra Help in all fifty states and DC receive low-income subsidies (LIS) for drug plan premiums, deductibles, and other forms of cost-sharing. Dual eligibles do not have to pay any drug plan premiums or deductibles. Dual eligibles that reside in long-term care facilities or get home-community based services also do not have to pay any copayment or coinsurance for drugs on their plan’s formulary.

Other dual eligibles, including those enrolled in Medicare Savings Programs (MSP), have to pay copayments of $1.20 for generic drugs and $3.70 for brand-name drugs if their income is at most the federal poverty level. If their income exceeds the federal poverty level, then they have to pay $3.30 for generic drugs and $8.25 for brand-name drugs. All dual eligibles with Extra Help are exempt from entering the coverage gap.



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