Understanding Medicare & Medicaid for Dually Eligible Beneficiaries

Dually eligible beneficiaries are individuals who qualify for both Medicare and Medicaid, making them eligible for a broad range of healthcare services. These beneficiaries typically have limited income and resources, qualifying them for additional support to cover healthcare costs that Medicare does not fully pay. Here’s a detailed guide to understanding the benefits, billing practices, and key considerations for healthcare providers dealing with dually eligible beneficiaries.

Who Are Dually Eligible Beneficiaries?

Dually eligible beneficiaries are those who qualify for Medicare Part A (hospital insurance), Part B (medical insurance), or both, and receive full Medicaid benefits or assistance with Medicare premiums and cost-sharing through specific Medicare Savings Programs (MSPs). The primary MSP categories include:

• Qualified Medicare Beneficiary (QMB): Covers Part A and Part B premiums, deductibles, coinsurance, and copayments.
• Specified Low-Income Medicare Beneficiary (SLMB): Covers only Part B premiums.
• Qualifying Individual (QI): Covers only Part B premiums for individuals who are not eligible for any other Medicaid benefits.
• Qualified Disabled Working Individual (QDWI): Covers Part A premiums for certain individuals under 65 who have returned to work.

Medicare is generally the primary payer for services, with Medicaid covering additional costs that Medicare does not, such as long-term care or home-based services.

Billing Prohibitions and Requirements

Healthcare providers must be particularly mindful when billing dually eligible beneficiaries, especially those under the QMB program. Key points include:

• Billing Prohibitions: Providers cannot bill QMB beneficiaries for Medicare Part A and B cost-sharing, such as deductibles, coinsurance, and copayments. Even if Medicaid does not fully cover these amounts, the provider must accept the Medicare and Medicaid payments as payment in full.
• Assignment Requirement: Providers must accept assignment, meaning they agree to accept the Medicare-approved amount as full payment for services provided to dually eligible beneficiaries.
• Advance Beneficiary Notice (ABN): In some cases, providers may issue an ABN if they expect Medicare to deny a service as not medically necessary. However, providers cannot charge the beneficiary up front and must follow specific guidelines if they plan to shift financial responsibility to the patient.

Important Resources

For further details and guidelines, healthcare providers can refer to:

• Medicare Claims Processing Manual, Chapter 1
• Medicare & Medicaid Basics
• CMS Qualified Medicare Beneficiary (QMB) Program

Understanding these rules ensures compliance and helps providers avoid penalties while ensuring that dually eligible beneficiaries receive the care they need without undue financial burden.