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Beneciaries Dually Eligible for Medicare & Medicaid
MLN006977 June 2024
What’s Changed?
Substantive content changes are in dark red.
We added information on Qualied Medicare Beneciary billing prohibitions (page 7).
Beneciaries Dually Eligible for Medicare & Medicaid MLN Fact Sheet
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Medicare & Medicaid Programs
Together we can advance
health equity and help eliminate
health disparities for all minority
and underserved groups. Find
resources and more from the
CMS Oce of Minority Health:
●
Health Equity Technical
Assistance Program
●
Disparities Impact
Statement
Medicare Program
Medicare is health insurance for:
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People age 65 or older
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Certain people under age 65 with disabilities and entitled
to Social Security disability or Railroad Retirement Board
(RRB) benets for 24 months (we waive the 24-month
waiting period for people with amyotrophic lateral sclerosis
(ALS), also known as Lou Gehrig’s disease)
●
People of any age with ESRD
Medicare has 4 parts:
1. Part A — Hospital Insurance includes inpatient hospital, inpatient skilled nursing facility (SNF),
hospice, and some home health services
2. Part B — Medical Insurance includes physician services,
outpatient care, DME, lab and X-ray services, home health
services, and many preventive services
3. Part C — Medicare Advantage (MA) (for example,
Health Maintenance Organizations (HMOs) or
Preferred Provider Organizations (PPOs)) is made up
of Medicare-approved private insurance companies that
provide all Part A and Part B services and may provide
prescription drug coverage and other supplemental benets
4. Part D — Prescription Drug Benet is made up of Medicare-approved private insurance
companies that provide prescription drug coverage
Enrollees may choose:
●
Part A and Part B services through Original Medicare with optional Part D coverage through an
approved stand-alone Medicare drug plan
●
Part A and Part B services through an MA Plan if they live in its service area, with a drug plan
included in most plans
Beneciaries Dually Eligible for Medicare & Medicaid MLN Fact Sheet
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Medicaid Program
Medicaid is a joint federal and state program that provides health insurance for certain people with
low income. Each state administers its own program, following broad national federal guidelines,
statutes, regulations, and policies. Each state:
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Establishes eligibility standards
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Decides type, amount, duration, and scope of services
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Sets payment rates
The Medicare Part D low income subsidy (LIS) program, also referred to as the Extra Help Program,
helps pay enrollees’ Medicare drug plan monthly premiums, annual deductibles, and copayments for
those who have or want Part D coverage and meet certain income and resource limits.
Dually Eligible Beneciaries
Dually eligible beneciaries are eligible for both Medicare and Medicaid. They include patients in
Medicare Part A, Part B, or both, and those getting full Medicaid benets or help with Medicare
premiums or cost-sharing through 1 of these Medicare Savings Program (MSP) eligibility groups:
●
Qualied Medicare Beneciary (QMB): Covers Part A and Part B premiums, deductibles,
coinsurance, and copayments.
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Specied Low-Income Medicare Beneciary (SLMB): Covers only Part B premiums.
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Qualifying Individual (QI): Covers only Part B premiums (people enrolled in this program can’t
have any other Medicaid eligibility).
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Qualied Disabled Working Individual (QDWI): Covers only Part A premiums for certain
people under age 65 with disabilities who return to work. Medicare pays covered dually eligible
beneciaries’ medical services rst because Medicare is the primary payer for items and services
that both programs cover. Medicaid may cover medical costs that Medicare doesn’t cover or
partially covers (for example, nursing home care, personal care, and home- and community-
based services). Beneciaries’ coverage can vary by state. Some Medicaid programs pay for care
directly through Fee-for-Service (FFS) coverage. Others oer Medicaid through managed care or
other integrated care models.
Medicare providers can’t
bill QMB patients for Medicare cost-sharing. This includes deductibles,
coinsurance, and copayments. In some cases, a patient may owe a small Medicaid copayment.
Medicare and Medicaid payments (if any) (and any applicable Medicaid QMB copayment) are
considered payment in full. You’re subject to sanctions if you bill a QMB above the total Medicare
and Medicaid payments (even when Medicaid pays nothing).
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States must cover mandatory services through their Medicaid programs, which include:
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Physician services
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Inpatient and outpatient hospital services
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Lab and X-ray services
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Nursing facility services
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Medication-assisted treatment
States may cover optional services, including:
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Dental services
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Other diagnostic screening, preventive,
and rehabilitative services
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Needed medications
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Physical therapy
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Prosthetic devices
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Vision and eyeglasses
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Children who are dually eligible beneciaries
get vision, dental, hearing, and other services
through the Medicaid Early and Periodic
Screening, Diagnostic, and Treatment
(EPSDT) benet
Federal law denes Medicaid and MSP income and resource standards, but states can raise
those limits above the federal oor using disregards (except for QDWIs). We update dually eligible
beneciary standards annually.
Tables 1–7 summarize the dually eligible categories, including each category’s benets and
basic qualications.
Table 1. Qualied Medicare Beneciary (QMB) Only Without Other Medicaid
Benets & Qualications Description
Benets
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Medicaid covers Part A (if any) and Part B premiums.
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Medicaid covers Medicare deductibles, coinsurance, and
copayments for Medicare-covered items and services. Even if
Medicaid doesn’t fully cover these charges, the QMB isn’t liable
for them.
Qualications
●
Income can be up to 100% of the federal poverty level (FPL).
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Resources can be up to 3 times the Supplemental Security
Income (SSI) resource limit, increased annually by the consumer
price index (CPI).
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Enrolled in:
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Part A
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For those without Part A, depending on the state, either:
▪
Part B only
▪
Part B and conditional Part A
Social Security Administration Program Operations Manual System
section HI 00801.140 has more information.
Beneciaries Dually Eligible for Medicare & Medicaid MLN Fact Sheet
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Table 2. Qualied Medicare Beneciary Plus (QMB+)
Benets & Qualications Description
Benets
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Medicaid covers Part A (if any) and Part B premiums.
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Medicaid covers Medicare deductibles, coinsurance, and copayments
for Medicare-covered items and services. Even if Medicaid doesn’t
fully cover these charges, the QMB+ isn’t liable for them.
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Get full-benet Medicaid coverage (see Table 7) plus Medicare
premiums and cost-sharing coverage.
Qualications
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Meet QMB-related eligibility requirements in Table 1.
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Enrolled in full Medicaid coverage (beyond Medicare premiums
and cost-sharing coverage).
Table 3. Specied Low-Income Medicare Beneciary (SLMB) Only Without Other Medicaid
Benets & Qualications Description
Benets Medicaid pays Part B premium.
Qualications
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Income between 100%–120% of FPL
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Resources can be up to 3 times the SSI resource limit, increased
annually by the CPI
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Enrolled in Part A
Table 4. Specied Low-Income Medicare Beneciary Plus (SLMB+)
Benets & Qualications Description
Benets
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Medicaid pays Part B premium
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Get full-benet Medicaid coverage (see Table 7) plus Medicare
Part B premium coverage
Qualications
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Meet SLMB-related eligibility requirements in Table 3
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Meet full-benet Medicaid eligibility requirements in Table 7
Table 5. Qualifying Individual (QI)
Benets & Qualications Description
Benets Medicaid pays Part B premium.
Qualications
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Income between 120%–135% of FPL
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Resources can be up to 3 times the SSI resource limit, increased
annually by the CPI
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Enrolled in Part A
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QI beneciaries aren’t eligible for any other Medicaid coverage
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Table 6. Qualied Disabled Working Individual (QDWI)
Benets & Qualications Description
Benets Medicaid pays Part A premium.
Qualications
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Income up to 200% of FPL.
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Resources up to 2 times the SSI resource limit.
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People under 65 with a qualifying disability who lost premium-free
Part A coverage after returning to work and now must pay a
premium to enroll in Part A. QDWI beneciaries aren’t eligible for
any other Medicaid coverage.
Table 7. Full-Benet Medicaid
Benets & Qualications Description
Benets
●
Full Medicaid coverage refers to the package of services
beyond Medicare premiums coverage and cost-sharing certain
beneciaries get when they qualify for certain eligibility groups
under a state’s Medicaid Program.
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States must cover some of these groups (like SSI recipients).
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States have the option to cover others, like the special
income level institutionalized beneciary group, home- and
community-based waiver participants, and medically
needy people.
●
Dually eligible beneciaries who get only Medicaid are enrolled
in Part A or Part B (or both) and qualify for full Medicaid benets
but not for MSP groups. States may pay their Part B premium.
Qualications
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States decide income and resource criteria.
●
States can require Part A or B enrollment if they pay the
beneciary’s premiums for these parts.
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Beneciaries must show they need a certain level of care or meet
state-specic medical criteria to qualify for certain categories.
Dually Eligible Beneciary Billing Requirements
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You must accept assignment for Part B-covered services provided to dually eligible beneciaries.
Assignment means the Medicare Physician Fee Schedule (PFS) amount is payment in full.
Special instructions apply when you provide an Advance Beneciary Notice (ABN) to a dually
eligible beneciary if you expect Medicare to deny the item or service because it isn’t medically
reasonable and necessary or is custodial care.
●
You can’t bill the dually eligible beneciary up front when you provide an ABN.
MLN Fact SheetBeneciaries Dually Eligible for Medicare & Medicaid
MLN006977 June 2024Page 7 of 8
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Once Medicare and Medicaid adjudicate the claim, you may charge the beneciary only in
these circumstances:
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If they have QMB coverage without full Medicaid coverage and Medicare denies the claim, the
ABN could allow you to shift nancial responsibility to them under Medicare policy.
●
If they have full Medicaid coverage and Medicaid denies the claim (or won’t pay because you
don’t participate in Medicaid), the ABN could allow you to shift nancial responsibility to them
under Medicare policy, subject to state laws that limit beneciary responsibility.
ABN Form and Instructions has more information.
QMB Billing Prohibitions
●
All Original Medicare and MA providers and suppliers (not only those that accept Medicaid) can’t
charge QMBs Medicare Part A and Part B cost-sharing for covered services.
●
Providers and suppliers may bill state Medicaid programs for these costs, but states can limit
Medicare cost-sharing payments under certain circumstances. This applies even if the provider or
supplier doesn’t participate in Medicaid.
Note: QMBs may have a small Medicaid copayment.
●
Providers should use the Medicare 270/271 HIPAA Eligibility Transaction System (HETS) and the
Medicare Remittance Advice and Medicare Summary Notice (MSN) messages to identify whether
a beneciary is a QMB and owes no Medicare cost-sharing.
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MA providers and suppliers should contact the MA Plan to learn the best way to identify the QMB
status of plan members both before and after claims submission.
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Providers and suppliers may verify beneciaries’ QMB status through automated Medicaid
eligibility-verication systems in the state where the person lives or by asking them for other proof,
like their Medicaid identication card, MSN, or other QMB status documentation.
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Providers who inappropriately bill people enrolled in QMB are subject to sanctions.
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If you bill a QMB Medicare cost-sharing, or turn a bill over to collections, you must recall it. If you
collect any QMB cost-sharing money, you must refund it.
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Providers and suppliers can’t charge people enrolled in QMB even if their QMB benet is from a
dierent state than the state where they get care.
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Certain types of providers may seek payment for Medicare deductible and coinsurance amounts
as a Medicare bad debt. The Provider Reimbursement Manual - Part 1 has more information
about bad debts.
Many beneciaries are unaware of the billing restrictions (or concerned about damaging relationships
with providers) and sometimes pay the cost-sharing amounts. Others may experience undue distress
when unpaid bills are referred to collection agencies. Access to Care Issues Among Qualied
Medicare Beneciaries (QMB) has more information.
MLN Fact SheetBeneciaries Dually Eligible for Medicare & Medicaid
MLN006977 June 2024Page 8 of 8
Resources
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Medicare Claims Processing Manual, Chapter 1
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Medicare General Information, Eligibility, and Entitlement, Chapter 2
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Medicare Patient Information
●
Medicare & Medicaid Basics
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Medicare Managed Care Manual
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Medicare-Medicaid Coordination Oce
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Medicare Prescription Drug Benet Manual
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Social Security Administration’s Role in MSP Applications
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of Health & Human Services (HHS).