Medicare dual eligible
Encyclopedia
Medicare dual eligibles, in the Medicare
system of the United States
, are Medicare Part A and/or B recipients who either [1] qualify for a Medicare Savings Programs (MSP) or [2] qualify for Medicaid
benefits. Dual eligibles generally qualify for the QMB benefits, in which the beneficiary's non-Medicare coverage is covered by Medicaid, effectively providing full health care coverage. With the advent of the Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, these dual eligibles have automatically been enrolled to a random Medicare Part D
plan, effective January 1 of 2006. As a result of this auto assignment, participants who were already enrolled in a Medicare Advantage HMO, may have been automatically disenrolled from their medical plan to allow for part D enrollment. Medicaid will still cover drugs for dual-eligible patients that are not covered by Medicare Part D, including certain controlled substances. Pharmacies know by automation who these patients are. Individuals that qualify for dual eligibility will be paid first by Medicare and the remainder will be paid by Medicaid.
Section 231 of the Medicare Modernization Act of 2003 created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs called the Medicare Advantage Special Needs Plans (SNP) program. "Special needs individuals" were identified by Congress as: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions. SNPs must offer care to the unique needs of low-income, chronically ill, and institutionalized Medicare beneficiaries. Given their expertise in serving these populations, many Medicaid managed care
plans also offer SNPs to serve dual eligibles. The program was set to expire in 2008 and has since received short term authorizations from Congress.
A study looking at physician's views of Medicare Part D, and in particular how it pertains to dual-eligibles, found that many physicians expressed concern regarding access to prescription drugs, especially for dual-eligibles. Almost half of physicians responded that the access to prescription drugs for dual-eligibles was worse under Part D than relative to the previous Medicaid, and more than half (63%) reported higher administration burden. Many physicians stated that dual-eligibles had less access to under Part D than in three Medicaid restrictive states. This suggests that the transparency of Part D formulary coverage needs to be improved to improve access to these resources for physicians. A further study by the same group of researchers found that despite the above physicians' views on access to healthcare among dual-eligibles, there was no statistically significant changes in pharmaceutical utilization or out-of-pocket expenditures in the 18 months after Medicare Part D implementation. When comparing a group of dual-eligibles (the experimental group) with a control group of near-elderly Medicaid-covered patients, both groups showed a decline in costs rights after the implementation of Part D, which then leveled off. The expenditures for both groups tracked each other.
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...
system of the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, are Medicare Part A and/or B recipients who either [1] qualify for a Medicare Savings Programs (MSP) or [2] qualify for Medicaid
Medicaid
Medicaid is the United States health program for certain people and families with low incomes and resources. It is a means-tested program that is jointly funded by the state and federal governments, and is managed by the states. People served by Medicaid are U.S. citizens or legal permanent...
benefits. Dual eligibles generally qualify for the QMB benefits, in which the beneficiary's non-Medicare coverage is covered by Medicaid, effectively providing full health care coverage. With the advent of the Medicare Prescription Drug, Improvement, and Modernization Act
Medicare Prescription Drug, Improvement, and Modernization Act
The Medicare Prescription Drug, Improvement, and Modernization Act is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health program's 38-year history.The MMA was signed by President George W...
of 2003, these dual eligibles have automatically been enrolled to a random Medicare Part D
Medicare Part D
Medicare Part D is a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries in the United States. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 and went into effect on January 1, 2006.- Eligibility and...
plan, effective January 1 of 2006. As a result of this auto assignment, participants who were already enrolled in a Medicare Advantage HMO, may have been automatically disenrolled from their medical plan to allow for part D enrollment. Medicaid will still cover drugs for dual-eligible patients that are not covered by Medicare Part D, including certain controlled substances. Pharmacies know by automation who these patients are. Individuals that qualify for dual eligibility will be paid first by Medicare and the remainder will be paid by Medicaid.
Section 231 of the Medicare Modernization Act of 2003 created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs called the Medicare Advantage Special Needs Plans (SNP) program. "Special needs individuals" were identified by Congress as: 1) institutionalized; 2) dually eligible; and/or 3) individuals with severe or disabling chronic conditions. SNPs must offer care to the unique needs of low-income, chronically ill, and institutionalized Medicare beneficiaries. Given their expertise in serving these populations, many Medicaid managed care
Medicaid managed care
Medicaid managed care provides for the delivery of Medicaid health benefits and additional services in the United States through an arrangement between a state Medicaid agency and managed care organizations that accept a set payment – “capitation” – for these services...
plans also offer SNPs to serve dual eligibles. The program was set to expire in 2008 and has since received short term authorizations from Congress.
A study looking at physician's views of Medicare Part D, and in particular how it pertains to dual-eligibles, found that many physicians expressed concern regarding access to prescription drugs, especially for dual-eligibles. Almost half of physicians responded that the access to prescription drugs for dual-eligibles was worse under Part D than relative to the previous Medicaid, and more than half (63%) reported higher administration burden. Many physicians stated that dual-eligibles had less access to under Part D than in three Medicaid restrictive states. This suggests that the transparency of Part D formulary coverage needs to be improved to improve access to these resources for physicians. A further study by the same group of researchers found that despite the above physicians' views on access to healthcare among dual-eligibles, there was no statistically significant changes in pharmaceutical utilization or out-of-pocket expenditures in the 18 months after Medicare Part D implementation. When comparing a group of dual-eligibles (the experimental group) with a control group of near-elderly Medicaid-covered patients, both groups showed a decline in costs rights after the implementation of Part D, which then leveled off. The expenditures for both groups tracked each other.
External links
- Medicare & You handbook (PDF) on Medicare.gov — see pages 49 (59 of 104) and 58 (68 of 104) for more complete information
- Medicare / Medicaid Dual Eligibles information from cms.hhs.gov
- Dual Eligible FAQ for claims processing by pharmacist (PDF) from cms.hhs.gov