What is a Dual-Eligible Beneficiary?
Dual-eligible beneficiaries are those who receive both Medicare and MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. benefits. It includes beneficiaries enrolled in Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and/or Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. while receiving full Medicaid and/or financial assistance through a Medicare Savings Program.
- Dual-eligible beneficiaries are those that qualify for both Medicare and Medicaid.
- When dually eligible, Medicare is the primary payer for all Medicare-approved healthcare services, while Medicaid or a Medicare Savings Program helps with the remaining out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments..
- When available, dual-eligible beneficiaries can join a Medicare AdvantageMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). Special Needs Plan.
What is Covered for a Dual-Eligible Beneficiary?
The level of coverage for a dual-eligible beneficiaryA person who has health care insurance through the Medicare or Medicaid programs. depends on whether they are a full benefit or partial benefit dual-eligible. Full benefit dual-eligible are enrolled in both Medicare and Medicaid. These programs work together to provide health care coverage, assistance with Medicare premiumsA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. and costs, and coverage for services that are not covered by Medicare alone, such as dental care, hearing care, and nursing homes.1Medicare.gov, “Medicaid“, Accessed October 26, 2021
Partial benefit dual-eligibles are enrolled in Medicare and a Medicare Savings Program. Medicare provides health care coverage for these beneficiaries while the Medicare Savings Programs would provide cost-sharing for remaining Medicare expenses.2Medicare.gov, “Medicare Savings Programs“, Accessed October 26, 2021
What Is Medicare?
Medicare is health insurance for adults of age 65 and over, as well as people with certain disabilities. Medicare pays for approximately 80 percent of the beneficiary’s costs for medically necessaryServices or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice. services. If beneficiaries cannot afford Medicare’s premiums, copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service., and coinsurances, then they can apply for Medicaid through their local Medicaid office.3Medicare.gov, “Medicare costs at a glance“, Accessed October 26, 2021
What Is Medicaid?
Medicaid is a combined state and federal program that provides healthcare for families and individuals whose annual income is at or below the federal poverty level. For Medicare beneficiaries, Medicaid works in conjunction with Medicare to help pay a beneficiaries out-of-pocket costs, including monthly premiums, deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., and copayments. Dually-eligible beneficiaries pay minimal copayments. In some states, Medicaid also provides coverage for routine care that Medicare does not cover, including routine dental, vision, and hearing.1Medicare.gov, “Medicaid“, Accessed October 26, 2021
Medicare Savings Program
Beneficiaries with an income level that is near the federal poverty line (FPL), under 200 percent of the FPL, but not below it can be partially dual-eligible when enrolled in Medicare and a Medicare Savings Program. Medicare Savings Programs include the Qualified Medicare Beneficiary (QMB) program, Specified Low-Income Medicare Beneficiary (SLMB) program, Qualifying Individual (QI) program, and Qualified Disabled and Working Individuals (QDWI) program. These savings programs provide assistance with Medicare premiums and cost-sharing with Medicare’s out-of-pocket costs.4CMS.gov, “Dually Eligible Beneficiaries Under Medicare and Medicaid“, Accessed October 15, 2021
Medicare Advantage Special Needs Plans
Dual-eligible beneficiaries are also eligible to join a Medicare Advantage Special Needs Plan (D-SNP), where available. Medicare Advantage SNP plans are coordinated care plans that handle coordinating costs between Medicare and Medicaid. All D-SNP plans include prescription drug coverage and have minimal out-of-pocket costs.5CMS.gov, “Dual Eligible Special Needs Plans (D-SNPs)“, Accessed October 15, 2021
- 1Medicare.gov, “Medicaid“, Accessed October 26, 2021
- 2Medicare.gov, “Medicare Savings Programs“, Accessed October 26, 2021
- 3Medicare.gov, “Medicare costs at a glance“, Accessed October 26, 2021
- 4CMS.gov, “Dually Eligible Beneficiaries Under Medicare and Medicaid“, Accessed October 15, 2021
- 5CMS.gov, “Dual Eligible Special Needs Plans (D-SNPs)“, Accessed October 15, 2021