Medicare and Medicaid - Patient Dual eligibility - Full review

The Medicare and Medicaid Programs

The Medicare Program

Medicare is health insurance for people 65 or older, certain people under 65 with disabilities, and people of any age with End-Stage Renal Disease.

Medicare consists of four different parts:

• Part A – Hospital insurance (inpatient hospital care, inpatient care in a Skilled Nursing Facility, hospice care, and some home health services);

• Part B – Medical insurance (physician services, outpatient care, durable medical equipment, home health services, and many preventive services);

• Part C – Medicare Advantage (MA) (Medicare-approved private insurance companies provide all Part A and Part B services and may provide prescription
drug coverage and other supplemental benefits); and

• Part D – The Prescription Drug Benefit (Medicare-approved private companies provide outpatient prescription drug coverage). Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help  Program, which helps pay for monthly premiums, annual deductibles, and copayments.

Medicare beneficiaries can obtain their Medicare coverage in the following ways:

• Receive Part A and Part B services through the Original Medicare Program. To obtain Part D coverage, they must join a stand-alone Prescription Drug Plan; or

• Receive Part A and Part B services from a MA Plan if they reside in its service area. Most MA plans include Part D coverage.

The Medicaid Program

The Medicaid Program is a cooperative venture funded by Federal and State governments that pays for medical costs for certain individuals and families with low incomes and, in some cases, limited resources.

Within broad national guidelines established by Federal statutes, regulations, and policies, each State:

• Establishes its own eligibility standards;
• Determines the type, amount, duration, and scope of services;
• Sets the rate of payment for services; and
• Administers its own program.

Dual Eligible Beneficiaries

“Dual eligible beneficiaries” is the general term that describes individuals who are enrolled in both Medicare and Medicaid. The term includes individuals who are enrolled in Medicare Part A and/or Part B and receive full Medicaid benefits and/or assistance with Medicare premiums or cost sharing through one of the following “Medicare Savings Program” (MSP) categories:\

• Qualified Medicare Beneficiary (QMB) Program – Helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments;
• Specified Low-Income Medicare Beneficiary (SLMB) Program – Helps pay for Part B premiums;
• Qualifying Individual (QI) Program – Helps pay for Part B premiums; and
• Qualified Disabled Working Individual (QDWI) Program – Pays the Part A premium for certain people who have disabilities and are working.

Medicare-covered services also covered by Medicaid are paid first by Medicare because Medicaid is generally the payer of last resort. Medicaid may cover the cost of care that Medicare may not cover or may partially cover (such as nursing home care, personal care, and home- and community-based services).

The options for dual eligible individuals to receive their Medicare and Medicaid benefits varies by State. In some States, dual eligible individuals receive Medicaid through Medicaid managed care plans, and in other States, Medicaid coverage may be Fee-For-Service. In some States, certain dual eligible individuals can join plans that include all Medicare and  Medicaid benefits.


The chart below provides additional information on dual eligible Medicaid programs.

Dual Eligible Medicaid Programs

Full Medicaid (only)

• Full Medicaid coverage either categorically or through optional coverage groups based on Medically Needy status, special income levels for institutionalized individuals, or home- and community-based waivers

• Medicaid may pay for Part A (if any) and Part B premiums and cost sharing for Medicare services furnished by Medicare providers to the extent consistent with the Medicaid State Plan


QMB Only 

≤100% of Federal Poverty Line (FPL)

• Medicaid pays for Part A (if any) and Part B premiums, and may pay for deductibles, coinsurance, and copayments for Medicare services furnished by Medicare providers to the extent consistent with the Medicaid State Plan (even if payment is not available under the State plan for these charges, QMBs are not liable for them)

QMB Plus 

≤100% of FPL

• Full Medicaid coverage

• Medicaid pays for Part A (if any) and Part B premiums, and may pay for deductibles, coinsurance, and copayments to the extent consistent with the Medicaid State Plan (even if payment is not available under the State plan for these charges, QMBs are not liable for them)


SLMB Only 

>100% of FPL but <120% of FPL

• Medicaid pays for Part B premiums


SLMB Plus 

>100% of FPL but <120% of FPL

• Full Medicaid coverage
• Medicaid pays for Part B premiums


QI
≥120% of FPL but <135% of FPL
• Medicaid pays for Part B premiums

QDWI 

≤200% of FPL

• Medicaid pays for Part A premiums