Federal Link: www.cms.gov/dualeligibles/ftshhmpg.asp
What is it: Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit.
Who qualifies: There are income limits www.cms.gov/dualeligibles/4732rate.asp
NOTE: There is usually a two-year Medicare waiting period for SSDI.
Exceptions:
3 MONTH WAIT for people with end-stage renal disease are eligible
for Medicare.
NO WAIT for people with amyotrophic lateral sclerosis (ALS, or
Lou Gehrig's disease)
- QMBs = QUALIFIED MEDICARE BENEFICIARIES Medicare
beneficiaries with incomes at or below the federal poverty level
are entitled to have Medicaid pay their Medicare premiums, deductibles,
and co-payments.
- SLMBS = SPECIFIED LOW-INCOME MEDICARE BENEFICIARIES
Medicare beneficiaries with incomes between 100 and 120 percent
of the poverty level are entitled to have Medicaid pay their Medicare
Part B premiums only.
- QIs = QUALIFIED INDIVIDUALS Medicare beneficiaries
with incomes between 120 percent and 135 percent of the federal
poverty level are eligible through a federal block grant program
to apply for payment of their Medicare Part B premiums.
- QDWIs = QUALIFIED DISABLED WORKING INDIVIDUALS
Working people with disabilities who receive Medicare and whose
incomes after disregards are less than 200 percent of poverty
level are entitled to full or partial payment of their Medicare
Part A premiums. States can opt either to cover premiums in full
or to charge QDWIs on a sliding-fee scale.
Medicaid Only Dual Eligibles (Non QMB, SLMB, QDWI, QI)
These individuals are entitled to Medicare Part A and/or Part B and are eligible for full Medicaid benefits. They are not eligible for Medicaid as a QMB, SLMB, QDWI, QI.
What it covers: Medicare Part A and/or Part B and some form of Medicaid benefit.
FEW OUT-OF-POCKET EXPENSES for people who qualify
for both Medicare and Medicaid p rovided the federal resource requirements
of less than $4,000 for an individual or $6,000 for a couple or
the state's more liberal resource requirements are met.
- QMB Only - Qualified Medicare Beneficiaries without other Medicaid
- Entitled to Medicare Part A, have income of 100% Federal poverty level (FPL) or less
- Resources that do not exceed twice the limit for SSI eligibility,
- Are not otherwise eligible for full Medicaid.
- Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for Medicare services provided by Medicare providers.
- QMBs PLUS QMB with full Medicaid
- Entitled to Medicare Part A, have income of 100% FPL or
less
- Resources that do not exceed twice the limit for SSI eligibility,
- Are eligible for full Medicaid benefits.
- Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance, and provides full Medicaid benefits.
- SLMB - Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid
- Entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL
- Resources that do not exceed twice the limit for SSI eligibility, and
- Are not otherwise eligible for Medicaid.
- Medicaid pays their Medicare Part B premiums only.
- SLMB PLUS - SLMBs with full Medicaid
- Entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL
- Resources that do not in exceed twice the limit for SSI eligibility, and
- Are eligible for full Medicaid benefits.
- Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits.
- QDWI - Qualified Disabled and Working Individuals
These individuals lost their Medicare Part A benefits due to their return to work.
- Eligible to purchase Medicare Part A benefits, have income of 200% FPL or less
- Resources that do not exceed twice the limit for SSI eligibility, and
- Not otherwise eligible for Medicaid.
- Medicaid pays the Medicare Part A premiums only.
What it costs: Varies state to state.
- State option - Payment by Medicaid of Medicare Part B premiums
- State option - Cover premiums in full or to charge QDWIs on a sliding-fee scale.
Impact for YOUTH: This is the tricky section of public benefits for youth who are working, staying under SGA income limits or able to defer earned income through work incentives off-sets. It can be an advantage for a youth whose health issues are progressive and work income not stable, having both benefits will reduce out-of-pocket expenses.
QDWIs = QUALIFIED DISABLED WORKING INDIVIDUALS
After working for a few years the individual will qualify for Medicare
and SSDI and due to low income or change in health issue may also
maintain Medicaid. This is why the term Dual Eligibles is used because
the person qualifies for both programs.
How to Apply: Contact State Medicaid/Medicare Office.
MEDICARE www.cms.hhs.gov/medicare/
MEDICAID www.cms.hhs.gov/medicaid/consumer.asp
Guides:
CENTERS FOR MEDICARE & MEDICAID SERVICES
CMS-Medicare/Medicaid Dual Eligible
www.cms.hhs.gov/dualeligibles/bene.asp
The purpose is to educate the Medicare/Medicaid Dual Eligible on qualifications, benefits and what is being done to reach out to these beneficiaries. Resource Guide (PDF 270K), Income limits, fact sheet and screening tool.
CMS-Medicare/Medicaid Dual Eligible Training Materials
cms.hhs.gov/dualeligibles/trnghmpg.asp
Overheads, materials, leaders notes and more.
Resources:
CMS - MEDICARE/MEDICAID DUAL ELIGIBLE
Income Limits Based on Percentage of Federal Poverty Level
www.cms.gov/dualeligibles/4732rate.asp
THE COMMONWEALTH FUND - TASK FORCE ON THE FUTURE OF HEALTH INSURANCE
Elimination of Medicare's Waiting Period for Seriously
Disabled Adults:
Impact on Coverage and Costs
 www.mathematica-mpr.com/PDFs/elimination.pdf
Medicare provides health insurance coverage to people with disabilities and chronic illnesses who are entitled to cash benefits under the Social Security Disability Insurance (SSDI) program. In most cases, however, these individuals must first wait five months for disability benefits and then an additional two years before they can receive Medicare benefits. We estimate that there were 1.26 million SSDI beneficiaries in the Medicare waiting period as of January 2002, all of whom are unable to work because of their disability and most of whom have serious health problems, low incomes, and limited access to health insurance. Our research shows that eliminating the two-year wait for Medicare could improve access to health insurance for many seriously disabled Americans, including as many as 400,000 who may be uninsured, those with Medicaid coverage who may have limited access to health benefits and providers, and those with private coverage who, because of their health problems, are paying unusually high premiums to maintain their coverage.
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