Dually Eligible Individuals

Dually Eligible Individuals - Categories

People who are dually enrolled in both Medicare and Medicaid, also known as dually eligible

individuals, fall into several eligibility categories. These individuals may either be enrolled first in

Medicare and then qualify for Medicaid, or vice versa.

Dually eligible individuals are enrolled in Medicare Part A (Hospital Insurance) and/or Part B

(Supplemental Medical Insurance), and are also enrolled in full-benefit Medicaid and/or the Medicare

Savings Programs (MSPs) administered by each individual state. MSPs are Medicaid eligibility

groups that assist low-income Medicare beneficiaries with some or all of their Medicare Parts A and B

expenses.

Medicare C

overage

Medicare coverage has four parts:

• Part A (Hospital Insurance) helps cover inpatient care in hospitals, as well as skilled nursing

facility, hospice, and home health care. Most individuals qualify for premium-free Part A (i.e.,

those who have worked the requisite quarters to qualify for Social Security benefits). However,

individuals ages 65 and older who lack a sufficient work history may obtain Part A benefits if

they qualify to pay a monthly premium or are enrolled in an MSP through which the state pays

the premium on their behalf. To enroll in premium Part A, individuals must live in the U.S.

and either be a U.S citizen or a Legal Permanent Resident who has lived in the U.S.

continuously for five years prior to the application.

• Part B (Supplemental Medical Insurance) helps cover doctor and other health care providers’

services, outpatient care, durable medical equipment, home health care, and some preventive

services. All beneficiaries pay a monthly Part B premium except for those enrolled in a MSP

that pays their Part B premium.

• Part C (Medicare health plans – also called Medicare Advantage) provides Part A and Part B

benefits to people with Medicare who enroll in these plans. Medicare Advantage is offered by

private companies that contract with Medicare to provide Part A and Part B benefits, and in

most cases, Part D. Dually eligible beneficiaries may also get help with Medicare Part C

costs.

o Plans that integrate Medicare coverage with Medicaid include Programs of All-

inclusive Care for the Elderly (PACE), Medicare-Medicaid Plans (MMPs), Fully

Integrated Dual Eligible Special Needs Plans, and Highly Integrated Dual Eligible

Special Needs Plans.

• Part D (outpatient prescription drugs) provides coverage of prescription drug costs through

private plans. Beneficiaries who enroll in Medicaid or an MSP automatically qualify for Extra

Help (also known as the Low-Income Subsidy program) to help pay for the costs — monthly

premiums, annual deductibles, and prescription copayments — related to Medicare Part D.

Medicaid Coverage

Medicaid provides health coverage to millions of Americans, including eligible low-income adults,

children, pregnant women, elderly adults, and people with disabilities. Medicaid is a state-based

program that is funded jointly by states and the federal government. Within broad national guidelines

established by federal statutes, regulations, and policies, each state has the flexibility to:

• Establish its own eligibility standards;

• Determine the type, amount, duration, and scope of services;

• Set the rate of payment for services; and

• Administer its own program.

Medicare and Medicaid cover many of the same services. All providers, including Medicare providers,

must enroll in their Medicaid system for Medicaid claims review, processing, and payment of

Medicare cost-sharing. Providers should contact the state Medicaid agency for additional information

regarding Medicaid provider enrollment.

Medicare pays first for Medicare-covered services that are also covered by Medicaid because Medicaid

is generally the payer of last resort. Medicaid may cover care that Medicare does not cover (such as a

variety of long-term services and supports).

Table 1 - Eligibility Categories and Assistance with Medicare Part A and Part B Costs

This section summarizes the eligibility categories for dually eligible individuals, including the degree to

which individuals in each category receive assistance with Medicare Parts A and B premiums and cost

sharing. Each eligibility category is mutually exclusive.

Category

Monthly

Income as

of 2023*

Assets as of

2023*

Covers Part

A premium

(when

applicable)

Covers

Part B

premiym

Covers

Parts A &

B cost

sharing

Full

Medicaid

coverage**

Married

Couple:

$6,659

Married

Couple:

$6,000

Full-benefit

Medicaid

(only)**

Determined

by state

Determined

by state

Varies by

state****

Varies by

state****

* The Centers for Medicare & Medicaid Services (CMS) releases the income and resource limits for all states and D.C annually. The income

limits for the MSPs include a standard disregard of $20 and for QDWI, earned income disregards. The asset limit calculation for QMBs,

SLMBs, and QIs is 3 times the SSI resource limit, adjusted annually by increases in the Consumer Price Index (effective January 1, 2010).

States can effectively raise the federal floor for income and resources standards under the authority of section 1902(r)(2) of the Social Security

Act, which generally permits state Medicaid agencies to disregard income and/or resources that are counted under supplemental security

income (SSI) financial eligibility methodologies. Some states have used the authority of section 1902(r)(2) of the Act to effectively eliminate

the asset test for the MSP groups. Higher income limits apply for Alaska and Hawaii.

** “Full-benefit” Medicaid coverage generally refers to coverage for a range of items and services, beyond coverage for Medicare

premiums and cost-sharing, that certain individuals are entitled to when they qualify under certain eligibility categories included in the State

Medicaid Plan (state plan). Individuals who are QMB/SLMB “plus” receive full-benefit Medicaid in addition to coverage of some or all

their Medicare Parts A and B expenses. Individuals who receive full-benefit Medicaid only are entitled to Medicare Part A and/or enrolled

in Part B, and qualify for full-benefit Medicaid benefits, but not the QMB or SLMB groups.

*** While individuals enrolled in QMB do not pay Medicare deductibles, coinsurance, or copays, they may have a small Medicaid copay for

certain Medicaid-covered services.

**** States pay the Part B premiums if they include all Medicaid eligibility groups in their buy-in agreement with CMS.

***** Beneficiary pays no more than amount allowed by the state plan for services covered by both Medicare and Medicaid. Also, all Medicare

providers (regardless of Medicaid participation) must accept the Medicare-allowed amount (“Medicare assignment”) as payment in full for Part B

services furnished to dual eligible beneficiaries.

Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only – also known as QMB

“partial benefit”) are enrolled in Medicare Part A (including premium Part A on an actual or conditional

basis), have income at or below 100% of the federal poverty level (FPL) and resources that do not exceed

three times the limit for supplementary security income (SSI) eligibility with adjustments for inflation, and

are not otherwise eligible for full-benefit Medicaid coverage. Medicaid pays their Medicare Part A

premiums, if any, and Medicare Part B premiums. Medicare providers may not bill QMBs for Medicare

Parts A and B cost-sharing amounts, including deductibles, coinsurance and copays.

Providers can bill Medicaid programs for these amounts, but states have the option to reduce or

eliminate the state’s Medicare cost-sharing payments by adopting policies that limit payment to the lesser of

(a) the Medicare cost sharing amount, or (b) the difference between the Medicare payment and the Medicaid

rate for the service.

QMBs with full–benefit Medicaid (QMB Plus) meet the QMB-related eligibility requirements described

above and the eligibility requirements for a separate “categorical” eligibility group covered under the state

Medicaid plan. In addition to the coverage for Medicare premiums and cost-sharing described above, QMB

“Plus” individuals are entitled to the full range of Medicaid benefits applicable to the separate eligibility

group for which they qualify. Medicaid pays their Medicare Part A premiums, if any, and Medicare Part B

premiums. Medicare providers may not bill QMBs for Medicare Parts A and B cost sharing amounts,

including deductibles, coinsurance, and copays. Providers can bill Medicaid programs for these amounts,

but states have the option to reduce or eliminate the state’s Medicare cost sharing payments by adopting

policies that limit payment to the lesser of (a) the Medicare cost sharing amount, or (b) the difference

between the Medicare payment and the Medicaid rate for the service. QMBs with full-benefit Medicaid pay

no more than the Medicaid coinsurance (if applicable) for services covered in the state plan (i.e., care that is

furnished by a Medicaid provider and that either: (1) Medicare and Medicaid, or (2) Medicaid, but not

Medicare, cover).

Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB-Only – also

known as SLMB “partial-benefit”) are enrolled in Part A and have income that is above 100 percent, but

less than120 percent of the FPL, and resources that do not exceed three times the limit for supplementary

security income (SSI) eligibility with adjustments for inflation. Medicaid pays only the Medicare Part B

premiums for this group.

Specified Low-Income Medicare Beneficiaries (SLMBs) with full-benefit Medicaid (SLMB Plus – also

known as SLMB “full benefit”) meet the SLMB-related eligibility requirements described above, and the

eligibility requirements for a separate “categorical” eligibility group covered under the individual’s state

Medicaid plan. In addition to the coverage for Medicare Part B premiums, these individuals receive full-

benefit Medicaid coverage (i.e., the package of benefits provided to the separate eligibility group for which

they qualify). SLMBs with full-benefit Medicaid pay no more than the Medicaid coinsurance (if applicable)

for services covered in the state plan (i.e., care that is furnished by a Medicaid provider and that either: (1)

Medicare and Medicaid, or (2) Medicaid, but not Medicare, cover). These individuals pay Medicare cost-

sharing for Medicare-covered care not included in the state plan unless the state chooses to pay these costs.

Qualifying Individuals (QIs) are enrolled in Part A and have income of at least 120% but less than 135%

of the FPL and resources that do not exceed three times the limit for supplementary security income (SSI)

eligibility with adjustments for inflation. QIs are never eligible for a separate eligibility group covered under

the state Medicaid plan. QIs receive coverage for their Medicare Part B premiums., to the extent their state

Medicaid programs have available funding. The federal government makes annual allotments to states to

fund the Part B premiums.

Qualified Disabled and Working Individuals (QDWIs – also known as QDWI “partial benefit”)

became eligible for premium-free Part A by virtue of qualifying for Social Security disability insurance, but

lost those benefits, and consequently Premium-free Medicare Part A, because they returned to work. QDWIs

must be otherwise ineligible for Medicaid and have income that does not exceed 200% of the FPL and

resources that do not exceed two times the SSI resource standard. Medicaid pays the Medicare Part A

premiums only.

Full-benefit Medicaid Only: These individuals are entitled to Medicare Part A and/or enrolled in Part B,

and qualify for full Medicaid benefits, but not the QMB or SLMB groups. Full-benefit Medicaid coverage

refers to the package of services, beyond coverage for Medicare premiums and cost-sharing, that certain

individuals are entitled to when they qualify under eligibility groups covered under a state’s Medicaid

program. Some of these coverage groups are ones states generally must cover (for example, supplemental

security income (SSI) recipients) and some are ones states have the option to cover (for example, the

“special income level” group for institutionalized individuals, home- and community- based services

(HCBS) programs participants, and “medically needy” individuals). Some of the services in the Medicaid

benefit package are ones Medicare does not cover, such as certain long-term services and supports (LTSS),

behavioral health, transportation, and vision services. Medicaid benefits vary by state. A full-benefit

Medicaid beneficiary pays no more than the Medicaid copay (if applicable) for services covered in the state

plan (i.e., care that is furnished by a Medicaid provider and that either: (1) Medicaid and Medicare, or

(2) Medicaid, but not Medicare, cover). These individuals pay Medicare cost-sharing for Medicare-covered

care not included in the state plan unless the state chooses to pay these costs.