I spent many years as a radiation oncology medical biller in an area with a significant senior population.  I would estimate that approximately 70% of our patient demographic was Medicare eligible beneficiaries with about half of those enrolled with the traditional Medicare plan. 

Most patients were financially able to have supplemental coverage, but we did have those few that were not.  Some qualified based on the state’s guidelines to have some type of Medicaid coverage as well.  This is what is referred to as “Dual Eligible Beneficiaries”.

Unfortunately, there are several different levels of Medicaid coverage that patients can qualify for, each with very distinctive benefits.  I was frequently frustrated trying to explain those benefit limitations to patients who really had no idea that their plan was not one that covered all their medical expenses after Medicare. 

For example, there is one plan that’s sole Medicaid covered benefit is to pay the Part B monthly premium.  It has no obligation to pay Medicare deductibles, co-insurances, etc.

As medical billers, we are often faced with trying to explain a patient’s coverage in “layman” terms in order to justify the out of pocket amounts we are attempting to collect.

 

Iridium Suite Practice Management Software has an integrated Real Time Eligibility that easily helps to identify dual eligible beneficiaries.

 

 

To help with this dual eligibility confusion, I located a great publication by CMS titled “Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs”.  You can locate it on their website www.cms.gov by entering this in the search bar: ICN006977.

In this publication, there is a very helpful chart that lays out the specifics of each of the possible Medicaid plans a Medicare beneficiary could be eligible for. 

There are two main categories: Full Medicaid or Special Need Plans.  (Most patients assume that they have the Full Medicaid, which is where most of the confusion occurs.)

The Special Need Plans is where it becomes more complicated.  This consists of four programs, some with sub-plans. Each has different eligibility qualifications and coverage benefits.  Below I listed the benefits of each:

1.       Qualified Medicare Beneficiary (QMB) Program

a.   QMB Only-Medicaid pays for Part A (if any) and Part B premiums, deductibles, coinsurance, and copayments for Medicare services furnished by Medicare providers to the extent consistent with Medicaid State Plan.

b.      QMB Plus- Medicaid pays for Part A (if any) and Part B premiums, deductibles, coinsurance, and copayments and Full Medicaid coverage to the extent consistent with State Plan.

2.       Specified Low-Income Medicare Beneficiary (SLMB) Program

a.       SLMB Only- Medicaid pays for Part B premiums.

b.      SLMB Plus- Medicaid pays for Part B premiums and Full Medicaid coverage to the extent consistent with State Plan.

3.       Qualifying Individual (QI) Program- Medicaid pays for Part B premiums.

4.       Qualified Disabled Working Individual (QDWI) Program- Medicaid pays for Part A premiums.

If Dual Eligibility left you scratching your head, hopefully this information has provided some insight that will assist you in your patient collections.