Dually eligible beneficiaries

Eligibility

A total of  10.7 million individuals were dually enrolled in Medicare and Medicaid in fiscal year 2013. The majority (59 percent) were age 65 and older. In total, dually eligible beneficiaries comprised 15 percent of all Medicaid beneficiaries but accounted for 33 percent of Medicaid spending.

Medicare is the primary payer for dually eligible beneficiaries and mainly covers medical services such as primary and specialty care, inpatient and outpatient acute care, and post-acute skilled-level care. Dually eligible beneficiaries are eligible for the same Medicare benefits as other Medicare beneficiaries but have low incomes that make it difficult to afford the premiums and cost sharing required by Medicare, as well as the cost of services not covered by the Medicare program.

Medicaid programs wrap around Medicare’s coverage by providing financial assistance in the form of payment of Medicare premiums and cost sharing, as well as coverage of additional benefits not offered under Medicare, such as long-term services and supports. Different types of dually eligible beneficiaries receive different levels of Medicaid assistance.

  • Partial benefits. Under mandatory Medicaid eligibility pathways referred to as Medicare Savings Programs (MSPs), dually eligible beneficiaries qualify for assistance limited to payment of Medicare premiums, or assistance with payment of both Medicare premiums and cost sharing. Individuals who only receive MSP assistance are referred to as partial-benefit dually eligible beneficiaries.
  • Full benefits. Among people with MSP coverage, some also qualify for the full range of services offered by state Medicaid programs under separate non-MSP pathways. These individuals who qualify for full Medicaid benefits are referred to as full-benefit dual-eligible beneficiaries. Most dually eligible beneficiaries (72 percent) were eligible for full Medicaid benefits in CY 2012.

The Medicaid benefit package varies depending on the type of dually eligible beneficiary. For many beneficiaries, Medicaid pays Medicare premiums and is the secondary payer of Medicare-covered services. For those with full Medicaid benefits, states must cover certain Medicaid services, such as Medicare cost sharing, inpatient hospital and nursing facility services when Medicare coverage is exhausted (that is, when limits on covered days are reached), nursing home care not covered by Medicare, and transportation to medical appointments.

About half of dually eligible beneficiaries who receive full Medicaid benefits qualify under a mandatory eligibility pathway based on their receipt of federal Supplemental Security Income (SSI) benefits. SSI is available to individuals with limited incomes (up to about 75 percent of the federal poverty level) and assets ($2,000 for an individual and $3,000 for a couple) who are under age 65 and disabled or who are age 65 and older. For most eligibility pathways that apply to people with disabilities and those age 65 and older, all states may opt to use less restrictive methodologies for counting income and resources to expand eligibility, and 209(b) states may opt to use more restrictive criteria.

Additional eligibility pathways are available to people with disabilities and individuals age 65 and older.

Click here for legislative milestones in Medicaid coverage of premiums and cost sharing for low-income Medicare beneficiaries.

TABLE 1. Eligibility for Medicare Savings Programs

Eligibility group Federal statutory and regulatory requirements State plan options
Dually eligible beneficiaries Medicare Savings Program (MSP)—Medicaid assistance for Medicare premiums and cost sharing

  • States must cover Medicare enrollees with resources below the standard for the Medicare Part D low-income subsidy in an MSP up to the following income levels:
    • qualified Medicare beneficiaries (QMBs) up to 100 percent FPL receive assistance with all Medicare premiums and cost sharing;
    • specified low-income Medicare beneficiaries (SLMBs) up to 120 percent FPL receive assistance with Medicare Part B premiums; and
    • qualifying individuals (QIs) up to 135 percent FPL receive assistance with Medicare Part B premiums.

MSP enrollees who are disabled

  • States must cover qualified and disabled working individuals (QDWIs) eligible for Medicare Part A (hospital) up to 200 percent FPL and asset below twice the standard of the SSI program.
MSP

  • States can effectively increase the income and asset eligibility standards above the federal MSP limits.

 

Source: MACPAC, 2017, Federal Requirements and State Options: Eligibility.
Learn more about policy issues affecting this population:

Beneficiaries Dually Eligible for Medicare and Medicaid

The Roles of Medicare and Medicaid for a Diverse Dual-Eligible Population

State Medicaid Payment Policies for Medicare Cost Sharing

Medicaid and Medicare Plan Enrollment for Dually Eligible Beneficiaries

Financial Alignment Initiative for Beneficiaries Dually Eligible for Medicaid and Medicare