MEDICARE—MEDICAID “DUAL ELIGIBLES”

Rachel B. Morgan RN, BSN 11/4/2013

Who Are the “Dual Eligibles”?

Approximately 10.2 million Americans qualify for coverage under both the Medicare and Medicaid programs. Often referred to as “dual eligibles,” these individuals are among the disabled, most chronically ill, and costly in either program. It’s been estimated that on average the dual eligible population costs 60 percent more than non-dual eligible individuals. Medicare covers their acute and post-acute care services, while Medicaid covers Medicare premiums and cost sharing, and—for those below certain income and asset thresholds—long-term care and social supportive services and, until 2006, prescription drugs, among other services. Approximately half initially qualify for Medicare because of disability rather than age and nearly one-fifth have three or more chronic conditions. More than 40 percent use long-term services or supports.  

This complex care population consumes a disproportionate share of both programs’ spending:

  • 16 percent of Medicare beneficiaries but one quarter of Medicare spending,
  • 18 percent of Medicaid enrollees but almost half of Medicaid spending.

What Medicaid Covers for Medicare Enrollees

Medicare has four basic forms of coverage:

  • Part A: Pays for hospitalization costs
  • Part B: Pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services
  • Part C: Medicare Advantage Plan( like an HMO or PPO) offered by private companies approved by Medicare
  • Part D: Assists with the cost of prescription drugs

Medicare enrollees who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medicaid (e.g. MSPs, QMBs, SLBs, and QIs). Medicaid also covers additional services beyond those provided under Medicare, including nursing facility care beyond the 100-day limit or skilled nursing facility care that Medicare covers, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the state's payment limit.

Medicare and Medicaid

Enrollee Category

Eligibility Level

(Federal Poverty Level)

Resource Standards What Medicaid Pays For

Qualified Medicare

Beneficiary (QMB)

100% FPL

$6,680/individual,

$10,020/couple

Part A premiums, Part B premiums, deductibles/coinsurance/copayments

Specified Low-Income

Medicare Beneficiary

(SLMB)

 

120% FPL

 

$6,680/ individual, $10,020/ couple

 

Part B premiums only

Qualified Individual (QI) 135% FPL $6,680/ individual, $10,020/ couple Part B premiums only

Qualified Disabled

Working Individual

(QDW)

 

200% FPL

 

$4,000/ individual,

$6,000/ couple

 

Part A premiums only

Resources and Information

The Centers for Medicare and Medicaid Services (CMS) Integrated Care Office

The Medicare-Medicaid Coordination Office works with the Medicaid and Medicare programs, across federal agencies, states and stakeholders to align and coordinate benefits between the two programs effectively and efficiently.

State Data Resource Center

Provides information on the resources available to State Medicaid Agencies for coordinating the care of individuals enrolled in both Medicare and Medicaid (Medicare-Medicaid enrollees). These resources include a description of the type of Medicare data available to agencies; assistance with requesting Medicare data from CMS, including outlines of the process for requesting Medicare data; and assistance on using Medicare data in coordinating the care of Medicare-Medicaid enrollees.

Integrated Care Resource Center

The Integrated Care Resource Center (ICRC) was established to help states develop integrated programs that coordinate the full range of medical, behavioral health, and long-term services and supports for individuals who are dually eligible for Medicare and Medicaid. Recognizing that states are at various stages of progress toward full integration, the resource center offers a variety of technical assistance services. The resources on this website, including materials developed by states, are continuously updated to reflect the lessons gleaned from on-the-ground experiences in developing integrated care programs.

Glossary of Terms Related to Dual-Eligible Beneficiaries of Medicare and Medicaid

CMS Research Review, 2013—"Effect of Long-term Care Use on Medicare and Medicaid Expenditures for Dual Eligible and Non-dual Eligible Elderly Beneficiaries"

Congressional Budget Office (CBO) Report—"Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies," June 2013

Integrated Care Resource Center: Available to All States
Resources Available to All States to Coordinate Care for High-Cost, High-Need Beneficiaries

Medicare-Medicaid Enrollee State Profiles

The Affordable Care Act (ACA) recognized the importance of Medicare-Medicaid enrollees to both programs by creating the Medicare-Medicaid Coordination Office (MMCO) within the CMS. The national summary, along with individual state profiles for each of the 50 states and the District of Columbia, was produced to facilitate greater understanding of the Medicare-Medicaid enrollee characteristics as states and CMS develop and test the effectiveness of integrated care models.

The national summary complements the individual profiles for each state and the District of Columbia. The state profiles offer state-level detail, while the national summary compares values across states. It provides a national composite sketch of Medicare-Medicaid enrollees including demographics, selected chronic conditions, service utilization, expenditures and availability of integrated delivery programs

Medicare-Medicaid Enrollee State Profile: The National Summary

Medicare-Medicaid Coordination Office

Created by the Affordable Care Act (ACA), the new Federal Coordinated Health Care Office (the Medicare-Medicaid Coordination Office) works to improve coordination between the federal government and states for Medicare-Medicaid enrollees in order to ensure full access to covered services in both programs and high quality care. The Office is moving forward on improving access, coordination, and cost of care with a focus in three major areas: Program Alignment, Data and Analytics, and Models and Demonstrations.

To date, the Medicare-Medicaid Coordination Office has:

  • Selected 15 States to receive contracts for up to $1 million each to design new integrated care models for people enrolled in Medicare and Medicaid. (CMS Fact Sheet)
  • The 15 States are California, Colorado, Connecticut, Massachusetts, Michigan, Minnesota, New York, North Carolina, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington and Wisconsin.
  • Initiated the process of creating a technical assistance center to help all states better meet the needs of these complex, high-cost beneficiaries.
  • Launched the Initiative to Align the Medicare and Medicaid Programs. The goal of this initiative is eliminate unnecessary and inefficient conflicts in the regulatory, statutory, and policy requirements of the two programs, where feasible.
  • Announced the availability of more timely Medicare Parts A, B, and D claims data for states to help them improve their care coordination for low-income seniors and people with disabilities who are enrolled in Medicare and Medicaid.
  • Developed a new demonstration program to test financial models designed to help states improve quality and share in the lower costs that result from better coordinating care. These models provide states with two new pathways to support integration for Medicare-Medicaid enrollees and provide opportunities to achieve savings as a result of improvements in care delivery.
  • Announced a new demonstration that will focus on reducing preventable inpatient hospitalizations among residents of nursing facilities by providing these individuals with the treatment they need without having to unnecessarily go to a hospital.