Medicare

Medicare and Medicaid Dual-Eligibility Information

Dual Eligible Programs (Sometimes Called Medicare Savings Programs)
The state has programs that are part of the Medicaid program (sometimes called Medical Assistance) that will pay some of the costs of Medicare. The programs have similar names but offer different benefits. They also have slightly different qualifications. Your client’s income and resources (if any) determine which program they can apply for.

These programs are called:

Qualified Medicare Beneficiary (QMB)

Specified Low-Income Medicare Beneficiary (SLMB)

Qualifying Individual (QI)

Qualified Disabled and Working Individual (QDWI)

Qualified Medicare Beneficiary (QMB) Program

Your Client May be Eligible for the Qualified Medicare Beneficiary (QMB) Program If:

• He/she is entitled to Medicare Part A (also known as hospital insurance). If they are not sure if they have Medicare Part A, they can look on their red, white, and blue Medicare insurance card or call Social Security toll-free at 1-800-772-1213 or TTY 1-800-325-0778. If they do not have Medicare Part A because they cannot afford it, the QMB program may pay the Medicare Part A premium for them.
• He/she has an income of 100 percent of the Federal Poverty Level or less and resources not exceeding twice the limit for SSI eligibility.

What expenses does the QMB program cover?

• Medicare Part A deductible
• Medicare Part B (also known as medical insurance) premium
• Medicare Part B deductible
• Co-insurance (co-insurance is typically 20% of approved Part B costs not paid
  to doctors by Medicare—this is normally the individual’s out-of-pocket expense)
• Co-insurance for extended hospital stays and skilled nursing
  (this is normally an out-of-pocket expense)
• In some cases, the Medicare Part A premium
• The cost of additional health services and prescriptions if your client qualifies for full Medicaid services as well (QMB Plus)

Specified Low-Income Medicare Beneficiary (SLMB) Program

Your Client May be Eligible for the Specified Low-Income Medicare Beneficiary (SLMB) Program If:

• He/she is entitled to Medicare Part A. Remember, if they are not sure if they have Medicare Part A, they can look on their red, white, and blue Medicare insurance card or call Social Security toll-free at 1-800-772-1213 or TTY 1-800-325-0778.
• He/she has an income above 100 of the Federal Poverty Level, but less than 120 percent of the Federal Poverty Level and resources not exceeding twice the limit for SSI eligibility

What expenses does it cover?

• Medicare Part B premium
• The cost of additional health services and prescriptions if they qualify for full Medicaid services (SLMB Plus).

Qualifying Individual (QI) Program

Your Client May be Eligible for the Qualifying Individual (QI) Program If?

• He/she is entitled to Medicare Part A
• He/she has an income at least 120 of the Federal Poverty Level, but less than 135 percent of the Federal Poverty Level and resources not exceeding twice the limit for SSI eligibility
• He/she is not otherwise eligible for Medicaid benefits

What expenses does it cover?

• Medicare Part B premium

How is the Qualifying Individual (QI) Program different from the Specified Low-Income Medicare Beneficiary (SLMB) Program?

• Each year, the state has only a certain amount of money for this program
• Once the money runs out, no one else will be enrolled.
• Eligible beneficiaries receive assistance on a first come, first served basis.
• Beneficiaries must re-apply for the program every year

Qualified Disabled and Working Individual (QDWI)

Who qualifies?

• People with disabilities who lost their Medicare Part A because they returned to work and are eligible to purchase Medicare Part A benefits
• He/she has an income of 200 percent of the Federal Poverty Level or less and resources not exceeding twice the limit for SSI eligibility
• An individual must not be otherwise eligible for Medicaid benefits

What expenses does it cover?

• Medicare Part A premium

If you think your client might qualify for one of these programs, here is what they need to do:

Make sure they have Medicare Part A. If you are not sure if they have Medicare Part A, look on their red, white, and blue Medicare insurance card if they have one, or call Social Security toll-free at 1-800-772-1213 or TTY 1-800-325-0778 to find out. If they do not have Medicare Part A because they cannot afford it, the QMB program may pay the Medicare Part A premium for them so they should still apply.

How do you enroll in the dual eligible programs (sometimes called Medicare Savings Programs)?
Although anyone can help complete an application for the dual eligible programs, only a state worker can determine if a person is eligible because the programs are part of the state Medicaid program (sometimes called Medical Assistance).

Call the local Medicaid office (medical assistance office) for your client and say you want information on the dual eligible programs (Medicare Savings Programs). Ask if your client can apply by phone, mail, or fax, or if they need to apply in person. Also ask what documents your client will need to provide. Each state is different.

Documentation varies in each state. Things the beneficiary may need:

• Medicare card
• Proof of identity
• Proof of residence
• Proof of income like pension checks or Social Security checks
• Recent bank statements
• Property deeds
• Insurance policies
• Financial statements for bonds or stocks
• Proof of funeral or burial policies

If your client becomes eligible, there may be a renewal (redetermination) process that he/she must follow to retain their benefits.
Once your client is determined eligible for Medicaid, the State must review his/her eligibility at least once a year or when there is a change in his/her circumstances, such as an increase or decrease in any cash assistance he/she might be receiving. Determinations of blindness and disability are not subject to annual redetermination.

During the renewal process the State is required to conduct an ex parte review. This means that states are required to rely on information that is available to State Medicaid Agencies, without contacting the client, in order to determine if the client remains eligible.

Your clients should not be required to provide information that:

• Is not relevant to their ongoing eligibility
• Has already been provided or relates to an eligibility factor that is not subject to change, such as date of birth or U.S. citizenship

Where to Call for More Information?
For more information, call the state Medicaid office (medical assistance office) or call Medicare’s 24-hour toll-free helpline at 1-800-Medicare (1-800-633-4227). TTY users should call 1-877-486-2048. When calling the toll-free helpline, ask for information on the Medicare Savings Programs.

Your State Health Insurance Assistance Program Can Also Help
There is a State Health Insurance Assistance Program (SHIP) in your state with volunteers who are available to discuss your client’s situation and provide information on available dual eligible options. For more information about the SHIP in your state, visit www.medicare.gov/contacts/related/ships.asp.

Where to Get Information on the Web?
To get information about the dual eligible programs (Medicare Savings Programs), visit the Centers for Medicare & Medicaid Services dual eligible Web site at www.cms.hhs.gov/dualeligibles.

You can also access Medicare & Medicaid dual eligible training materials on the Centers for Medicare & Medicaid Services Web site at http://www.cms.hhs.gov/dualeligibles/trnghmpg.asp.