What are Dual Eligibles, and why is everyone talking about them?
Simply put, dual eligibles are individuals who are eligible for both Medicare and Medicaid. These individuals are typically part of an under-served market and are eligible for a year-round SEP based upon their low income status.
As most of you know, Medicare is a federal program with deductibles and cost sharing associated with Parts A, B, and D. Medicaid is a federally funded but state run program. Because the funds come from the federal government, the feds get to tell the states what they MUST cover. The states determine on their own if they WANT to cover additional benefits. An individual who has both Medicare and Medicaid is entitled to have all of their cost sharing for Parts A and B paid for by Medicaid. For beneficiaries of a Part D Benefit, Medicare will automatically enroll them into a Part D plan that has a premium below the regional benchmark.
If a beneficiary has Medicare and has all of their cost sharing paid for by Medicaid, why would a Medicare Advantage plan be a good fit? It is really simple…Dual Eligibles receive EXTRA BENEFITS!!! A D-SNP (Dual Special Needs Plan) typically covers additional benefits such as dental, routine eye exams and eyeglasses. Some D-SNPs include transportation, hearing aids and over-the-counter benefits as well! The downfall to an MA plan is most D-SNP’s are HMO’s with specific doctor networks. The good news is that Medicaid beneficiaries are already accustomed to using Medicaid networks and getting referrals, so the fact that most D-SNP’s are HMO plans is not a detrimental factor in most cases.
Dual Eligibles are Members of Medicare Savings Plans or MSP’s
All states have Medicare Saving Programs (MSP’s) as well. Medicare Savings Plans pay for Part B premiums if you make below a certain income limit. For instance, SLMB’s can make up to 120% of the Federal Poverty Level (FPL) and are guaranteed to get their Part B premium paid for by the state. QI-1’s can make up to 135% of the FPL, but the funds to pay the Part B premiums are first come first served and are NOT guaranteed by the state to be available to pay the Part B premiums. Each state Medicaid sets their own rules and regulations for benefits in that state depending upon income and other factors.
Every year I meet two or three people who do not know about these Medicare Savings Plans, or that they may be eligible to receive Low Income Subsidy (LIS) benefits to reduce their prescription drug costs. Once I sit down with these folks at the kitchen table and help them see real savings, I know I’ve made a meaningful impact in their life! By spending just a few minutes on this, I can add a lifetime client to my book of business who is more than happy to send friends and family my way.
You can save your client up to $300 a month or more by helping them apply for LIS and other Medicare Savings programs. Most programs do not require them to be full Dual Eligibles. Individuals who make between 100-135% of the Federal Poverty Level (FPL) can apply to have their Medicare Part D premium covered and their prescription cost sharing significantly reduced as well as their Medicare Part B premium covered. Click here for a link to your state’s programs.
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