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Dual Eligible Beneficiaries

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DUAL ELIGIBLE BENEFICIARIES
“Dual eligible beneficiaries” generally describes beneficiaries eligible for both Medicare and Medicaid.
The term includes beneficiaries enrolled in Medicare Part A and/or Part B and receiving full Medicaid
benefits and/or assistance with Medicare premiums or cost sharing through one of these Medicare
Savings Program (MSP) categories:
● Qualified Medicare Beneficiary (QMB) Program: Helps pay premiums, deductibles, coinsurance,
and copayments for Part A, Part B, or both programs
● Specified Low-Income Medicare Beneficiary (SLMB) Program: Helps pay Part B premiums
● Qualifying Individual (QI) Program: Helps pay Part B premiums
● Qualified Disabled Working Individual (QDWI) Program: Pays the Part A premium for certain
disabled and working beneficiaries
Medicare pays covered medical services first for dual eligible beneficiaries because Medicaid is
generally the payer of last resort. Medicaid may cover medical costs that Medicare may not cover or
partially covers (such as nursing home care, personal care, and home- and community-based services).
Medicare and Medicaid dual eligible benefits vary by State. Some States offer Medicaid through
Medicaid managed care plans, while other States provide Fee-For-Service Medicaid coverage. Some
States provide certain dual eligible beneficiary plans that include all Medicare and Medicaid benefits.
Federal law defines income and resource standards for full Medicaid and the MSPs, but States have
discretion to effectively raise those limits above the Federal floor. On an annual basis, the Centers for
Medicare & Medicaid Services (CMS) releases dual eligible standards. The Medicare Savings Programs
section on the next page provides additional information.
 
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Article details
Article ID: 106
Category: Insurance Billing
Date added: 23-Jan-2019 4:44pm
Views: 21
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