Approximately 10 million people are enrolled in both Medicare and Medicaid. That’s about one-out-of-five Medicare enrollees.
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 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:
The following table illustrates the dual eligible standards for 2020. Income is represented by monthly amounts, not annual:
|Qualified Medicare Beneficiary (QMB)||Specified Low-Income Medicare Beneficiary (SLMB)||Qualifying Individuals (QI)||Qualified Disabled Working Individuals (QDWI)|
|All (except AK & HI) + DC||$1,084||$1,457||$1,296||$1,744||$1,456||$1,960||$4,339||$5,833|
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:
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 $3.60 for generic drugs and $8.95 for brand-name drugs. All dual eligibles with Extra Help are exempt from entering the coverage gap.
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