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Medicare / Medicaid Dual Eligibles

Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit.

Medicare - Medicaid Relationship

The Medicare Program (Title XVIII of the Social Security Act) provides hospital insurance, also known as Part A coverage, and supplementary medical insurance, also known as Part B coverage. Coverage for Part A is automatic for people age 65 or older (and for certain disabled persons) who have insured status under Social Security or Railroad Retirement. Most people don't pay a monthly premium for Part A.  Coverage for Part A may be purchased by individuals who do not have insured status through the payment of monthly Part A premiums. Coverage for Part B also requires payment of monthly premiums.

People with Medicare who have limited income and resources may get help paying for their out-of-pocket medical expenses from their state Medicaid program. There are various benefits available to "dual eligibles" who are entitled to Medicare and are eligible for some type of Medicaid benefit.  These benefits are sometimes also called "Medicare Savings Programs" (MSP).

For people who are eligible for full Medicaid coverage, the Medicaid program supplements Medicare coverage by providing services and supplies that are available under their states Medicaid program. Services that are covered by both programs will be paid first by Medicare and the difference by Medicaid, up to the states payment limit. Medicaid also covers additional services (e.g., nursing facility care beyond the 100 day limit covered by Medicare, prescription drugs, eyeglasses, and hearing aids).

Limited Medicaid benefits are also available to pay for out-of-pocket Medicare cost-sharing expenses for certain other Medicare beneficiaries. The Medicaid program will assume their Medicare payment liability if they qualify. Qualified Medicare Beneficiaries (QMBs), with resources at or below twice the standard allowed under the Supplemental Security Income (SSI) program and income at or below 100% of the Federal poverty level (FPL), do not have to pay their monthly Medicare premiums, deductibles, and coinsurance. Specified Low-Income Medicare Beneficiaries (SLMBs), with resources at or below twice the standard allowed under the SSI program and income exceeding the QMB level, but less than 120% of the FPL, do not have to pay the monthly Medicare Part B premiums. Qualifying Individuals (QIs), who are not otherwise eligible for full Medicaid benefits and with resources at or below twice the standard allowed under the SSI program, will get help with their monthly Medicare Part B premiums, if their income exceeds the SLMB level, but is less than 135% of the FPL.

Individuals who were receiving Medicare due to disability, but have lost entitlement to Medicare benefits because they returned to work, may buy Medicare Part A. If the individual has income below 200% of the FPL and resources at or below twice the standard allowed under the SSI program, and they are not otherwise eligible for Medicaid benefits, they may qualify to have Medicaid pay their monthly Medicare Part A premiums as Qualified Disabled and Working Individuals (QDWIs).

To learn more about Medicaid eligibility and/or the Medicare Program, see Related Links Inside CMS at the bottom of the page.

Screening Tools

Screening tools are available to help assess an individual's eligibility for a variety of governmental programs, including Medicaid and/or Medicare, by accessing the GovBenefits and BenefitsCheckUp websites.  (See Related Links Inside CMS and Related Links Outside CMS at the bottom of page.)

Integrated Medicare and Medicaid Models

CMS has created a specific website to provide information about our initiative for Integrated Care programs.  This website provides valuable resources regarding integrated Medicare and Medicaid programs for States, health plans, and providers.  This website can be accessed under Related Links Inside CMS below.



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Page Last Modified: 11/24/2008 6:20:23 AM
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