What Is a Dual Eligible? Medicare & Medicaid Benefits Working Together

What Is a Dual Eligible?

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A dual eligible is someone who has Medicare coverage and also gets assistance from Medicaid. Medicare is a federal health insurance program for the elderly and disabled. Medicaid is a state-based social welfare program providing health coverage for certain low-income people.

How Medicare & Medicaid Work Together for a Dual Eligible Beneficiary

If you’re a dual eligible, Medicare is your primary health insurance.

Think of it as your main health insurance. Think of Medicaid as similar to supplemental health insurance: it fills in some of the gaps left uncovered by Medicare.

Just what gaps, specifically, Medicaid fills in depends on whether you’re a full coverage dual eligible or a partial coverage dual eligible. For some dual eligibles, Medicaid provides financial aid by paying their Medicare Part B premiums, Medicare Part A premiums if they have any, and may pay all or part of their Medicare cost-sharing expenses like deductibles, copayments, and coinsurance. For other dual eligibles, Medicaid provides health insurance benefits not included in their Medicare coverage like dental, vision, and hearing benefits and coverage for long-term care like nursing homes.

Partial benefit dual eligibles are people who qualify for some financial aid from Medicaid but don’t meet eligibility criteria to get full Medicaid coverage benefits.

This financial aid is provided through one of several programs called Medicare Savings Programs. The four Medicare Savings Programs are

  • the Qualified Medicare Beneficiary (QMB) Program,
  • the Specified Low-Income Medicare Beneficiary (SLMB) Program,
  • the Qualifying Individual (QI) Program,
  • the Qualified Disabled Working Individual (QDWI) Program.

    Full benefit dual eligibles are people who qualify for full Medicaid benefits. In most instances, like partial benefit dual eligibles, full benefit dual eligibles also get help paying their Medicare premiums and cost-sharing expenses. In addition, they get full Medicaid coverage benefits. If you’re a full benefit dual eligible, what your Medicaid benefits specifically include depends on the state you live in.

    Medicaid eligibility and benefits vary from state to state. The federal government provides broad guidelines regulating Medicaid eligibility and coverage. Each state designs its own Medicaid program within the framework set forth by the federal government. Although states have to follow federal guidelines in setting up a Medicaid program and deciding which benefits to offer and who is eligible, these guidelines offer significant design flexibility. This design flexibility means that a person eligible for Medicaid in one state might not be eligible if they moved to another state. Also, the Medicaid benefits offered in one state might not be identical to the benefits offered in another state.

    The Affordable Care Act & Dual Eligibles

    Recognizing that dual eligibles include some of the nation’s most medically fragile and financially fragile residents, the authors of the Affordable Care Act addressed dual eligibles specifically by establishing two new federal entities: The Federal Coordinated Health Care Office and the Center for Medicare and Medicaid Innovation.

    The Federal Coordinated Health Care Office makes sure that Medicare and Medicaid benefits are effectively integrated for dual eligibles and that the federal and state governments coordinate in the delivery of those benefits. In a nutshell, it’s in charge of getting Medicare and Medicaid to work well together. 

    The Center for Medicare and Medicaid Innovation is tasked with developing new ways for health care services to be delivered to dual eligibles and new ways to structure payment for those services. The goal of these innovations is to increase the quality of the health care provided to dual eligibles while also reducing the cost of that care.

    Sources

    Affordable Care Act Provisions Relating to the Care of Dually Eligible Medicare and Medicaid Beneficiaries. The Henry J. Kaiser Family Foundation. Accessed June 7, 2015.

    Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs. The Department of Health & Human Services, Centers for Medicare & Medicaid Services, Medicare Learning Network. Accessed June 7, 2015.

    Medicare-Medicaid Enrollee Categories. Centers for Medicare & Medicaid Services, Federal Coordinated Health Care Office. Accessed June 7, 2015.

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