The recent changes to Medicare SEPs for full, partial and LIS only members has caused some people to ask questions about Full vs Partial Dual Eligibility.
Watch a quick YouTube video on the Dual eligible SEP changes
Full Dual Eligibility
Individuals who are eligible for both Medicaid and Medicare are dual eligible. In other words, To have full dual eligibility, it means you qualify for full Medicaid benefits from your state as well as Medicare. Medicare covers most healthcare benefits, although Medicaid pays some out-of-pocket costs such as premiums, copays, coinsurance and deductibles as well as long-term care.
Those who are dual eligible may qualify for a DSNP plan. A DSNP plan is a kind of Medicare Advantage plan that provides additional benefits not provided by Medicare or Medicaid.
Partial Dual Eligibility
If an individual is Partial dual eligible, it means their income level qualifies them for an MSP (Medicare Savings Program). Each state manages the MSPs using their Medicaid program. MSPs cover some Medicare costs, such as Part A & Part B premiums. It is important to note; partial dual eligibility doesn’t provide the same medical benefit coverage as full Medicaid.
Some individuals who qualify as partial dual may also qualify for a DSNP (Dual Special Needs) plan. Although Medicare pays most of the health care benefits, partial duals are responsible for out-of-pocket costs.
How a MSP helps partial duals
When Medicare enrollees receive medical care, Medicare doesn’t cover the entire cost of the services. There is usually an amount that’s left over. This amount is the beneficiaries’ responsibility and is called cost share or out-of-pocket cost and includes copays, coinsurance premiums and deductibles. This amount is the responsibility of the member. This who are enrolled in an MSP may receive help from Medicaid in paying for some of those costs. The amount of help (or cost sharing) received from Medicaid depends on income level and assets (such as real estate).
The 4 types of partial dual eligibles
QMB – Qualified Medicare Beneficiary
Members who receive help at the QMB level receive helps paying for premiums for Medicare Parts A & B as well as some cost shares for deductibles, copays and coinsurance.
SLMB – Specified Low Income Medicare Beneficiary
The SLMB program provides help with Part B premiums only.
QI – Qualified Individual
Those at the QI level receive help with Part B premium payments, these individuals may have a higher income than SLMB recipients.
QDWI – Qualified Disabled and Working Individuals
Individuals on QDWI program receive helps paying Medicare Part A premiums (hospital insurance) . This level of help applies to disabled individuals who have returned to work and lost their premium-free Medicare Part A coverage.