Dual Healthcare Coverage For Medicare/medicaid Beneficiaries

By Author: William Richards
Total Articles: 366
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Are you a “dual eligible?” That is, someone who qualifies for both Medicare and Medicaid coverage?

“If you’re a dual eligible,” says Alan Weinstock, an insurance broker at MedicareSupplementPlans.com, “Medicare will cover your acute care services, while Medicaid covers Medicare premiums and cost sharing. The term “dual eligible” is used to describe all Medicare beneficiaries who receive Medicaid assistance, including those who receive the full range of Medicaid benefits and those who receive assistance only with Medicare premiums or cost sharing.”

Who is a Dual Eligible?

To be a dual eligible you must meet certain eligibility requirements of both Medicare and Medicaid. Once you meet those requirements, you can enroll in both programs.

Medicare beneficiaries can quality for Medicaid based on income and resource requirements or if they have high medical bills. While there are generally several categories under which you may be eligible, eligibility standards and the scope of benefits available is set by each state and based on the federal guidelines.

Full Dual Eligibles Programs

First, ...
... there are the full dual eligibles. Full dual eligibles typically qualify to receive full Medicaid benefits. In addition Medicaid pays for Medicare Part A (if necessary), Medicare Part B premiums and cost sharing for all Medicare Part A and B services. To be eligible you must have an income less than or equal to 73% of poverty (Supplemental Social Security eligibility level) and assets not in excess of $2,000 for individuals and $3,000 for couples, though states can set the asset level higher. You can also receive full Medicaid benefits if your medical expenses are high enough to reduce your net income below a state-specified level.

Additionally, there are two other programs. The Special Income Rule for Nursing Home Residents (or 300 Percent Rule) allows beneficiaries with an income of up to 300% of SSI eligibility level to receive full Medicaid benefits, Medicare Part B premiums and cost sharing if you are in an institution. The Home- and Community-Based Services Waivers program provides Medicaid-covered home- and community-based services if you are eligible for Medicaid and residing in an institution.

Medicare Savings Program

There are four Medicare Savings Programs: Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualifying Individual (QI) and the Qualified Disabled & Working Individuals (QDWI). Here’s how to qualify for each:

Program Individual Mo. Income Couple Mo. Income Helps Pay
QMB Max $923.00 Max $1235.00 Medicare Part A & B premiums and other cost sharing
SLMB Max $1,103.00 Max $1477.00 Medicare Part B premiums only
QI Max $1,239.00 Max $1660.00 Medicare Part B premiums only
QDWI Max $3,695.00 Max $4942.00 Medicare Part A premiums only

If you have Medicare Part A, your income is below the income limits listed above and your resources are below $4,000 for an individual or $6,000 for a couple, you may be eligible for one of these four programs. Keep in mind these amounts are as of 2010 and may change in the future.

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