Dual Eligible Medicare Medicaid
Managing health coverage might be complicated, but for those who qualify, being dual-eligible for Medicare and Medicaid could simplify it.
This vital coverage could offer eligible individuals expansive healthcare at minimal cost.
This guide outlines who qualifies for dual eligible Medicare Medicaid, potential benefits, and gives 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, possibly providing them with comprehensive healthcare coverage and financial assistance for premiums and cost-sharing.
- Certain Medicare Savings Programs, such as QMB, SLMB, and QI, could be essential supplements for dual-eligible individuals, potentially offering assistance with Medicare premiums and certain out-of-pocket costs, with eligibility criteria that might include income and resource limits that may vary annually.
- Care coordination between Medicare and Medicaid for dual-eligible beneficiaries will likely be crucial to achieving comprehensive healthcare coverage, with various state strategies in place to manage this complex relationship, which may involve 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.
Being dual-eligible means you may carry primary health insurance coverage through Medicare and receive supplemental assistance from the state Medicaid program. This combination of programs could provide comprehensive healthcare coverage and might act 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 meet the low-income criteria to be eligible for Medicaid.
You could get dual-eligible beneficiary status by enrolling in Medicare Part A and Part B and participating in Medicaid, either as a full-benefit recipient or through Medicare Savings Programs.
It’s a comprehensive approach to healthcare coverage, potentially ensuring that those who qualify could have access to a wide range of critical services.
Why is Dual Eligibility Important?
By merging the potential benefits of Medicare with Medicaid, dual-eligible individuals could gain comprehensive healthcare coverage. This collaboration of programs may result in a more robust safety net for those who need it most.
Dual-eligible beneficiaries may also be financially supported by Medicaid in terms of assistance with certain Medicare premiums and cost-sharing. Additionally, Medicaid may also provide coverage for some healthcare services not included in Medicare, possibly offering a broader range of care options to dual eligibles.
Long-term services and supports (LTSS), which may be essential for many beneficiaries with chronic conditions or disabilities, could 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 will likely be designed to assist partial-benefit dual-eligible members with various Medicare premiums and cost-sharing. Some of these programs could ensure that dual-eligible members, categorized into ‘partial dual’ and ‘full dual,’ could be supported in their healthcare needs.
States may have a ‘spend down’ program that could enable individuals whose incomes are too high for standard Medicaid eligibility to qualify by using their medical expenses as a potential method to lower their countable income and meet Medicaid requirements. These programs could serve as a bridge in providing comprehensive healthcare coverage.
Qualified Medicare Beneficiary (QMB) Program
The QMB Program could act as a significant support system for dual-eligible members. It could cover:
- Medicare Part A and Part B premiums
- Deductibles
- Copayments
- Coinsurance for services and items approved by Medicare
This may help alleviate the financial burden of healthcare costs for dual eligibles.
Qualified Medicare Beneficiaries (QMBs) may also be safeguarded by balance billing protection, which may be able to prevent providers from charging more than the combined payments of Medicare and Medicaid.
Specified Low-Income Medicare Beneficiary (SLMB) Program
The SLMB Program will likely serve as a crucial support for individuals enrolled in both Part A and Part B of Medicare.
The potential income and resource limits may be 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 could offer additional support within the Medicare Savings Programs. This program could assist with paying certain Medicare Part B premiums for eligible individuals who may not be qualified for Medicaid.
Applications for QI benefits must be submitted every year and will likely be 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
The coordination between Medicare and Medicaid for dual-eligible beneficiaries could be vital for securing comprehensive healthcare coverage. Some of the State Medicaid programs may employ a variety of strategies, including requirements for coordinated care and payment of Medicare cost-sharing within certain care plans.
Some programs like Medicare-Medicaid Plans (MMPs) may be examples of the Financial Alignment Initiative where a unified health plan could manage the potential Medicare and Medicaid benefits. These initiatives, along with others like Medicaid managed care, PACE programs, and D-SNPs, may be 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 may play the role of the primary payer. Medicare will likely serve as the primary payer for services covered by Medicare, while Medicaid may provide supplemental coverage.
Dual-eligible beneficiaries could be automatically enrolled in a Medicare drug plan for prescription coverage; this may be separate from Medicaid drug coverage.
For non-QMB dual eligibles, Medicaid agencies will likely be responsible for paying the Medicaid rate for Medicaid-covered services received from Medicaid providers.
In certain states, managed care plans may be employed to facilitate the coordination of potential benefits for dual-eligible individuals.
Coordinating Care: Navigating the Health Care System
Dual-eligible individuals may encounter difficulties with care coordination due to the separate eligibility requirements, possible benefits, and rules of Medicare and Medicaid, which could lead to a fragmented healthcare system.
To combat this, some of the states may develop strategies for care coordination for dual-eligible members, with certain Medicaid-managed care plans having a significant role in delivering Medicaid benefits and covering Medicare cost-sharing.
An integrated approach to care may also be needed to improve health delivery for dual-eligible beneficiaries, such as requiring accountability for quality and costs across both programs and policy support.
Enhanced management of care transitions, such as moving from hospital to home, may also be crucial for dual-eligible beneficiaries to potentially 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, these plans could play a critical role in providing tailored coverage for dual eligibles.
D-SNPs will likely be offered in several states and the District of Columbia, with approximately 3.8 million dual-eligible beneficiaries enrolled as of February 2022.
States that might offer this plan will likely peruse integrated care models that may include the Financial Alignment Initiative for dual-eligible beneficiaries to improve care and potentially reduce costs.
What are D-SNPs?
D-SNPs are a type of Medicare Advantage (Part C) plan that may be designed specifically for those who qualify for both Medicare and Medicaid, to manage care and coordinate multiple plan coverage.
To qualify for a D-SNP, an individual must be enrolled in Medicare Part A and Part B and may also receive Medicaid benefits or assistance with Medicare premiums or cost-sharing.
These plans, known as Medicaid plans, could provide Medicare-covered services and may also coordinate or cover certain Medicaid benefits as per state requirements.
These may be the most common type of dual-eligible plan, which could potentially integrate benefits across both Medicare and Medicaid programs. In addition to standard Medicare services, D-SNPs may also offer supplemental benefits that may be covered by Medicaid, such as:
- Dental care
- Vision
- Hearing aids
- Non-emergency transportation
Possible Benefits of Enrolling in a D-SNP
D-SNPs could offer a wealth of benefits, including:
- Improved care integration mandated by federal requirements through state-specific contracts
- Additional benefits that might not be covered by original Medicare or Medicaid.
- Better health outcomes and patient satisfaction
These potential benefits could contribute to the overall effectiveness of D-SNPs.
Moreover, members of D-SNPs may be able to incur little to no out-of-pocket costs for certain healthcare services, which could contribute to financial relief and potentially decrease overall healthcare expenditures for dual-eligible individuals.
This could be a testament to the significant role D-SNPs might play in ensuring the welfare of dual-eligible members.
Long-Term Services and Supports (LTSS) for Dual Eligible Beneficiaries
Full-benefit dual-eligible members will likely have access to the complete range of full Medicaid benefits, which could encompass long-term services and support that might not be covered by Medicare. These potential Medicare benefits, along with Medicaid services, could be critical in providing comprehensive healthcare coverage to those who need it most.
Full dual-eligible members may also have access to various healthcare services, particularly LTSS, which might not be covered by Medicare, unlike partial dual-eligible members who could receive assistance with certain Medicare premiums and cost-sharing.
Fully integrated dual-eligible special needs plans (FIDE SNPs) and highly integrated dual-eligible special needs plans (HIDE SNPs) may offer dual-eligible members a complete integration of care, including LTSS.
Home and Community-Based Services (HCBS)
The Program of All-Inclusive Care for the Elderly (PACE) will likely be offered as an HCBS option that could provide comprehensive medical and social services to dual-eligible individuals who meet specific criteria, blending Medicare and Medicaid services for these beneficiaries.
Dual-eligible beneficiaries could maintain their Medicaid benefits when enrolling in a D-SNP, including access to personal care services, possibly ensuring continuity of care.
HCBS options like Nevada D-SNPs could enhance the coverage for dually eligible beneficiaries by potentially incorporating additional services such as:
- Dental care
- Vision services
- Hearing coverage
These potential services could 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 may also play a significant role in providing long-term care for dual-eligible members. Services like nursing homes and intermediate care facilities could offer essential support for those who may require more intensive care.
Some of these facilities could provide an array of services, which could allow dual-eligible members to receive the care they need. Some of the services provided by institutional care facilities may include:
- Medical care
- Assistance with daily activities
- Social and recreational activities
- Mental health support
- Rehabilitation services
These services will likely be designed to ensure the well-being and comfort of dual eligibles.
Possible Financial Incentives and Cost Sharing for Dual Eligibles
Depending on the dual eligibility category, various Medicare Savings Programs may serve as a safety net for beneficiaries by providing Medicare coverage and potentially covering costs such as:
- Medicare Part A and B premiums
- deductibles
- coinsurance
- copayments
These potential financial incentives and cost-sharing measures may be able to significantly reduce the financial burden of healthcare for dual-eligible members.
The scope of assistance each beneficiary could receive may vary by category, possibly affecting income qualifications, covered benefits, and restrictions. Understanding these variations could be crucial in making the most of your potential dual eligibility benefits.
Premium Assistance: How Medicaid Helps Pay Medicare Premiums
The majority of full-benefit dual-eligible individuals may be able to benefit from the premium and cost-sharing assistance that might be offered by the Medicare Savings Program. Medicare may also pay some of the monthly premiums for Medicare Part B for individuals who qualify for full Medicaid coverage, while Medicaid could pay 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 could play a vital role in ensuring comprehensive healthcare coverage for dual eligibles.
Reduced Out-of-Pocket Costs: Copayments, Deductibles, and Coinsurance
Dual-eligible beneficiaries may 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 may 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 call one of our licensed agents at 1-833-641-4938 (TTY 711), Mon-Fri 8 am-9 pm EST.
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.
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 before 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.
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 potential benefits could be crucial for those who qualify for both Medicare and Medicaid.
From comprehensive healthcare coverage to potentially reduced out-of-pocket costs, dual eligibility could potentially ensure that those who need it the most could have access to the care they deserve.
Certain programs like Medicare Savings Programs, D-SNPs, and LTSS could provide a safety net, possibly easing the financial burden of healthcare and offering a more integrated and coordinated care approach.
Navigating the complexities of dual eligibility might be challenging, but the benefits it could offer will likely be worth it.
Frequently Asked Questions
→ Why do people have both Medicare and Medicaid?
People might 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) will likely 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 will likely be covered by both Medicare and Medicaid, Medicare may pay first for the services received, and Medicaid might pay last, after Medicare and any other health insurance.
→ What is dual-eligible Medicare-Medicaid in Florida?
In Florida, dual eligibility for Medicare and Medicaid might mean individuals can be enrolled in both Medicare and full Medicaid or Medicare and one of Medicaid’s Medicare Savings Programs, which could help pay for Medicare premiums. This could provide primary and supplemental health insurance coverage for eligible individuals.
→ What is Medicaid?
Medicaid is a joint federal and state program that could provide health coverage to over 72.5 million Americans with disabilities, low-income families, children, pregnant women, parents, and seniors. These plans have been designed to assist people with limited income and resources in covering some of their 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.