Dually eligible beneficiaries are people enrolled in both Medicare and Medicaid who are eligible by virtue of their age or disability and low incomes. This is a diverse population that includes people with multiple chronic conditions, physical disabilities, mental illness, and cognitive impairments such as dementia and developmental disabilities. It also includes individuals who are relatively healthy. Show
Medicare is the primary payer for acute and post-acute care services. Medicaid wraps around Medicare by providing assistance with Medicare premiums and cost sharing and by covering some services that Medicare does not cover, such as long-term services and supports (LTSS). Key facts:There were 12.2 million dually eligible beneficiaries enrolled in both programs in calendar year 2019. In 2019, the most recent year of comprehensive data for both programs, a majority were:
Dually eligible beneficiaries accounted for a disproportionate share of spending:
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Featured publicationsOctober 2022 | Dually Eligible Beneficiaries Federal and state policymakers are interested in integrating care for beneficiaries dually eligible for Medicare and Medicaid to improve outcomes for the population and potentially reduce spending in both programs. A variety of models seek to do this, including the Program of All-Inclusive Care for the Elderly (PACE), the Financial Alignment Initiative (FAI), Medicare Advantage … August 2022 | Dually Eligible Beneficiaries In a response to a request for information included in the Centers for Medicare & Medicaid Services (CMS) proposed rule: Medicare program; Request for Information on Medicare, 87 Fed. Reg. 46918 (August 1, 2022), MACPAC outlined how integrating care for people who are dually eligible for Medicare and Medicaid has the potential to improve beneficiary … June 2022 | Dually Eligible Beneficiaries In a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks LaSure, MACPAC commented on the following proposed rule: Medicare Program; Implementing Certain Provisions of the Consolidated Appropriations Act, 2021 and Other Revisions to Medicare Enrollment and Eligibility Rules, 87 Fed. Reg. 25090 (April 27, 2022). Over the past several years, the … This guidance explains how states are expected to report dual-eligible beneficiaries in the T-MSIS Eligible File. Background DiscussionDual-eligible beneficiaries are individuals who receive both Medicare and Medicaid benefits. The two programs cover many of the same services, but Medicare pays first for the Medicare-covered services that are also covered by Medicaid. Medicaid covers services that Medicare does not cover, and these benefits are outlined in detail in this guidance. ContextMedicareAn individual is eligible for Medicare if he or she is 65 or older, younger than 65 with disabilities, or has end-stage renal disease. There are four parts of Medicare coverage:
All dual-eligible beneficiaries qualify for full Medicare benefits, but the level of benefits for which they are eligible under Medicaid can vary, generally depending on the beneficiary’s income and asset levels. Dual-Eligible BeneficiariesDual-eligible beneficiaries (or “duals”) are enrolled in Medicare Part A and/or Part B, and in Medicaid (full benefits) and/or in Medicare Savings Programs (MSPs). MSPs cover costs such as Part A premiums and Part A and B deductibles, coinsurance, and copayments, depending on the program. The dual-eligible population falls into two groups—“partial duals” and “full duals”—depending on the level of Medicaid benefits for which an individual is eligible. Because duals can typically account for a disproportionate share of both Medicare and Medicaid spending, researchers and policymakers often examine this population to better understand how to improve the delivery of care for these individuals whose health care needs can be quite diverse. Partial duals are so called because Medicaid pays some of the expenses they incur under Medicare. These expenses include the premiums for Part B and for Part A, if applicable. Medicaid may also pay for some other cost-sharing amounts owed under Medicare, such as deductibles, coinsurance, and copayments. Partial duals qualify for these cost-sharing benefits from Medicaid if they are disabled and working, and if they have an income above the state’s full Medicaid threshold but below 125 percent of the federal poverty level (FPL), or 200 percent FPL. These partial duals are assigned the following codes in T-MSIS: DUAL-ELIGIBLE-CODE ‘01’ (Qualified Medicare Beneficiary [QMB] only), ‘03’ (Specified Low Income Medicare Beneficiary [SLMB] only), ‘05’ (Qualified Disabled and Working Individual [QDWI]), or ‘06’ (Qualifying Individual (QI]). In addition to the benefits to which partial duals are entitled, full duals are entitled to Medicaid coverage for various health care services that Medicare does not cover, such as most types of long-term services and supports. Duals with lower income and asset levels fall into the full duals category and receive the full Medicaid benefits that their state offers. These full duals are assigned one of three codes in T-MSIS: DUAL-ELIGIBLE-CODE ‘02’ (QMB-plus), ‘04’ (SLMB-plus), or ‘08’ (Other full dual). Duals can fall into several MSP categories that offer various benefits, impose certain restrictions, and differ based on income:
Medicaid income qualifications, covered benefits, and restrictions depend on the category into which a dual eligible falls. Please see Table 1 for further details on covered benefits for duals. Table 1. Benefits covered by Medicaid Dual eligibility groupsMedicare Part A premiums(when applicable)Medicare Part B premiumsCo-insurance under Medicare Part A and Part BFull Medicaid coverageQMB OnlyXXXQMB PlusXXXXSLMB OnlyXSLMB PlusXXQDWIXQIXOtherX ChallengeStates have been reporting dual status for many years in MSIS, and many of them generally have enough reliable information about beneficiaries who meet the criteria for the various dual classifications; however, with the transition to T-MSIS, some states are migrating their dual assignments to new systems. States might therefore need to review the processes through which they report duals in T-MSIS, such as how to report QMB or SLMB populations who are eligible only for premium or deductible payments from Medicaid. Other states might need clarification on how to use the broader classifications that include code 08 (Other dual eligible beneficiaries [Non QMB, SLMB, QDWI or QI], also known as other full duals), code 09 (Other), and code 10 (Separate CHIP Eligible is entitled to Medicare). There are many dual eligible categories and as a consequence, many different codes required to report in T-MSIS depending on the categories a dual falls into. States may need clarification on which codes to use based on eligibility group. States may also need guidance on how to report with other eligibility segments, managed care plans, and Medicare premium payment reporting. CMS GuidanceDetailed Reporting Expectations in T-MSISThe State Medicare Modernization Act (MMA) Files of Dual Eligibles are considered to be reliable, current sources of information on the dual-eligible population. States submit these files monthly to CMS for purposes related to the administration of Medicare Part D benefits. Because the T-MSIS and MMA counts by dual code both count the same populations on a monthly basis, they are expected to be generally consistent. States can therefore consider these MMA files as a useful resource for validating dual code classifications in T-MSIS (see Appendix M, “Crosswalk of T-MSIS, MSIS and MMA Dual Eligible Code” in the T-MSIS Data Dictionary). It is also important to remember the intent behind dual codes 08 and 09, which are broader dual categories, to ensure that they are being assigned correctly:
Reporting Duals and Primary Eligibility GroupWhen reporting DUAL-ELIGIBLE-CODE, PRIMARY-ELIGIBILITY-GROUP-IND should always be set to “1” (Yes). The PRIMARY-ELIGIBILITY-GROUP-IND field is used to flag this eligibility segment as the key, or “primary,” eligibility classification that should be associated with a given person. Some state systems maintain records for individuals with who are in multiple eligibility groups that have overlapping periods of time. For any given time period that a person is eligible, only one eligibility segment should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = “1” (Yes). The second eligibility segment (and any others) for the same period should be assigned “0” (No) to flag that it is not the primary eligibility group. DUAL-ELIGIBLE-CODE is considered to be the primary eligibility group classification for duals, so states should report this code as the primary eligibility classification, and they should set the other segments to “0”. States may assign different case numbers to each beneficiary’s Medicaid and Medicare eligibility, but only one case number can be in a segment that is flagged as the segment with the primary eligibility group value. States should report one segment for each case number, when applicable. For more information on eligibility segments, please see the Primary Eligibility Group Indicator guidance. Reporting Dual-Eligible Beneficiaries and Managed CareIf a dual-eligible beneficiary is in Medicaid managed care or Medicare-Medicaid integrated care including PACE, D-SNPs, and Medicare-Medicaid Plans (MMPs), states should report the following data elements in the Managed-Care-Participation segment (MANAGED-CARE-PARTICIPATION-ELG00014) in the Eligible File: What is a dual eligible special needs plan quizlet?Dual-Eligible Special Needs Plan (D-SNP) Qualify for Medicare and Medicaid (based on income) Medicaid: A joint federal and state program that helps with medical costs. Medicaid typically pays for: Part B Premium.
What is dual eligible Medicare Medicaid in Florida?Definitions: Dual Eligibles are individuals entitled to Medicare who are also eligible for some level of Medicaid benefits. Full dual eligibles qualify for full Medicaid benefits, including long-term care provided in both institutions and in the community as well as prescription drugs.
What is the highest income to qualify for Medicaid?Federal Poverty Level thresholds to qualify for Medicaid
For example, in 2022 it is $13,590 for a single adult person, $27,750 for a family of four and $46,630 for a family of eight. To calculate for larger households, you need to add $4,720 for each additional person in families with nine or more members.
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