Dual-eligible

What does it mean to be dual-eligible?

People enrolled in both Medicare and Medicaid are called dual-eligible beneficiaries. This includes people enrolled in Medicare Part A and Part B who are getting all Medicaid benefits or assistance through a Medicare Savings Program. Medicaid beneficiaries are automatically eligible for Medicare when they turn 65 and retain their Medicaid eligibility. Depending on income, beneficiaries may have full coverage. Medicaid may just pay the Part B deductible for those with high income.

Medicare Savings Programs

There are four Medicare Savings Programs. These include the Qualified Medicare Beneficiary Program, the Specified Low-Income Medicare Beneficiary Program, the Qualifying Individual Program, and the Qualified Disabled Working Individual Program. Eligibility is based on assets and income. Each program covers a differing amount of Original Medicare expenses, similar to how Supplement Plans work.

The Qualified Medicare Beneficiary (QMB) program is for the lowest monthly incomes, of less than $1,084 for an individual and $1,457 for couples. The QMB program covers these individuals’ Part A and Part B premiums, deductibles, copayments, and coinsurance.

The Specified Low-Income Medicare Beneficiary (SLMB) program helps people with a monthly income less than $1,296 for individuals and $1,744 for couples. The SLMB program covers the Part B premium.

The Qualified Individual (QI) program is for individuals with monthly incomes less than $1,456 and for couples with monthly incomes less than $1,960. The QI covers the Part B premium.

The first three programs have a resources requirement of less than $7,860 for individuals and $11,800 for couples.

The Qualified Disabled and Working Individual (QDWI) program covers individuals with a monthly income less than $4,338 and less than $4,000 in resources, and covers couples with a monthly income less than $5,832 and less than $6,000 in resources. The plan covers the Medicare Part A premiums for disabled individuals younger than age 65 who lost their premium-free Part A because they returned to work.

How are Costs Covered

Medicare pays toward medical expenses first, followed by Medicaid. Medicaid can cover some things that Medicare does not, including nursing home care, personal care, and home- and community-based services. 

Billing requirements specific to Qualified Medicare Beneficiaries protect them from financial stress. Qualified Medicare Beneficiaries are protected from billing for cost-sharing. If a provider charges a beneficiary for Medicare cost-sharing or turns a bill over to collections, they have to recall it. 

Dual-eligible beneficiaries will be covered for all Part B services provided by a Medicare provider.

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