What Does it Mean to be Dual Eligible?

If you qualify for both Medicare and Medicaid, you have the option to enroll in a Dual Eligible Special Needs Plans, also known as a D-SNP. You qualify for Medicare if you are 65 or older, under 65 but with certain disabilities, or you have End-Stage Renal Disease (ERSD). Medicaid is a health care program that provides coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by the state (according to federal requirements), while Medicare is a federal government program. Medicare-covered services also covered by Medicaid are first paid by Medicare because Medicaid is the payer of last resort.

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Are You Dual Eligible?

You probable already know if you are on Medicare, but maybe not if you qualify for Medicaid. There are different levels of Medicaid eligibility based off of income level and availability of resources (your assets).

  • Qualified Medicare Beneficiary (QMB) Program – Your income is at or below the Federal Poverty Line (FPL) with resources that do not exceed two times the Supplementary Social Security Income (SSI) resource limit. Medicaid helps pay for Part A and/or Part B premiums, deductibles, coinsurance and copayments.
  • QMB Plus – This is for individuals that meet the above criteria but also meet other financial criteria for full Medicaid benefits; this is full Medicaid coverage.
  • Specified Low-Income Medicare Beneficiary (SLMB) Program – This applies to a person with an income over the Federal Poverty Line, but less than 120% of FPL. Medicaid helps pay for Part B premiums
  • Qualifying Individual (QI) Program – This applies to a person with an income over 120% of the FPL but less than 135% of FPL, and resources that do not exceed two times the SSI. Medicare helps pay for Part B premiums
  • Qualified Disabled Working Individual (QDWI) Program -Medicaid pays the Part A premium for certain people who have disabilities and are working. This would apply to an individual who has lost Medicare Part A benefits due to returning to work, but is eligible to enroll in Part A. The individuals income may not exceed 200% of FPL and resources may not exceed 2 times the SSI limit.

Because Medicare is administered by the state, options for dual eligible individuals vary from state to state. Some plans will only apply to full dual eligible beneficiaries. However, there are options for you if you are only part eligible for Medicaid! Learn more about your Medicaid eligibility HERE.

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