Dually Eligible Individuals - Categories

October 18th, 2022

1 min read

3:05

Dual-eligible beneficiaries are individuals who qualify for both Medicare and Medicaid benefits. These individuals often fall into specific categories based on their income, resources, and level of assistance needed from Medicaid.

Here’s an overview of the main dual-eligible categories:

1. Qualified Medicare Beneficiary (QMB)

Eligibility: Individuals with incomes at or below 100% of the Federal Poverty Level (FPL) and limited resources.
Benefits: Medicaid covers Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments.
Key Point: QMBs essentially have "full dual" coverage, with Medicaid paying for costs that Medicare doesn't cover.

2. Specified Low-Income Medicare Beneficiary (SLMB)

Eligibility: Individuals with incomes between 100% and 120% of the FPL and limited resources.
Benefits: Medicaid pays for Medicare Part B premiums only.
Key Point: SLMBs receive partial dual eligibility, with limited Medicaid assistance for premiums.

3. Qualified Individual (QI)

Eligibility: Individuals with incomes between 120% and 135% of the FPL and limited resources.
Benefits: Medicaid pays for Medicare Part B premiums.
Key Point: QI benefits are subject to limited federal funding and may not always be available; beneficiaries must reapply each year.

4. Qualified Disabled and Working Individual (QDWI)

Eligibility: Disabled individuals under age 65 who lost their Medicare Part A benefits because they returned to work and whose incomes are below 200% of the FPL.
Benefits: Medicaid pays for Medicare Part A premiums only.
Key Point: QDWI benefits are focused on individuals who are working and have lost Medicare coverage due to income increases.

5. Full Dual Eligible (also known as Full-Benefit Dual Eligible)

Eligibility: Individuals who qualify for both full Medicaid benefits and Medicare benefits.
Benefits: Full Medicaid benefits in addition to Medicare; Medicaid may also help cover Medicare premiums, deductibles, and copayments.
Key Point: Full dual-eligible beneficiaries receive comprehensive coverage, including Medicaid benefits like prescription drugs and additional support.

6. Partial Dual Eligible

Eligibility: Individuals who qualify for limited Medicaid assistance with Medicare premiums and cost-sharing but do not receive full Medicaid benefits.
Benefits: Medicaid only helps with specific Medicare expenses, such as Part B premiums (similar to QMB, SLMB, and QI categories).
Key Point: Partial duals benefit from financial assistance but do not receive the additional healthcare services available to full dual-eligible beneficiaries.

Check out this resource that summarizes the eligibility categories for dually eligible individuals, including the degree to which individuals in each category receive assistance with Medicare Parts A and B premiums and cost sharing. Each eligibility category is mutually exclusive.

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Topics:

Medicare Advantage

Medicare Sales

Dual Eligibles

DSNP

Dually Eligible Individuals - Categories

1. Qualified Medicare Beneficiary (QMB)

2. Specified Low-Income Medicare Beneficiary (SLMB)

3. Qualified Individual (QI)

4. Qualified Disabled and Working Individual (QDWI)

5. Full Dual Eligible (also known as Full-Benefit Dual Eligible)

6. Partial Dual Eligible

Helpful Resources: An Agents Guide to Marketing DSNP plans

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