Dual Eligible Beneficiary

Key facts

Coordinating office

CMS Medicare-Medicaid Coordination Office, created by the ACA

Payment order

Medicare pays first; Medicaid is the payer of last resort

Drug coverage

Medicare Part D, with automatic Extra Help (Low-Income Subsidy)

Partial-benefit categories

QMB, SLMB, QI and QDWI under the Medicare Savings Programs

Integrated plans

Dual Eligible Special Needs Plans (D-SNPs)

What is a dual eligible beneficiary?

People become dual eligible when they qualify for Medicare, usually by age or disability, and also meet their state's Medicaid income and asset rules. Dual eligible beneficiaries tend to have more chronic conditions, disabilities and long-term care needs than other Medicare beneficiaries, and they account for a disproportionate share of spending in both programs.

Medicare is the primary payer for services both programs cover. For full-benefit dual eligibles, Medicaid then fills gaps: Medicare premiums and cost sharing, plus services Medicare does not cover, such as long-term nursing home care and many home and community-based services.

Types of dual eligibility

CMS separates full-benefit from partial-benefit dual eligibles. Partial-benefit groups get help through the Medicare Savings Programs, which states run under Medicaid:

• Full-benefit dual eligible: qualifies for full Medicaid benefits, often with Medicare Savings Program help as well.
• Qualified Medicare Beneficiary (QMB): Medicaid pays Medicare Part A and Part B premiums, deductibles, coinsurance and copayments.
• Specified Low-Income Medicare Beneficiary (SLMB): Medicaid pays the Part B premium.
• Qualifying Individual (QI): Medicaid pays the Part B premium, subject to limited federal funding.
• Qualified Disabled and Working Individual (QDWI): Medicaid pays the Part A premium for certain working people with disabilities.

Why dual eligibility matters

Dual eligibles sit at the boundary of two payers with different rules, which creates billing and care coordination problems. Providers generally may not bill Qualified Medicare Beneficiaries for Medicare deductibles or coinsurance, a protection CMS has repeatedly reminded providers about.

For health plans, dual eligibles are a major growth segment through D-SNPs, and CMS policy has been moving toward plans that integrate Medicare and Medicaid benefits under one organization. For pharma and provider targeting, dual eligible status is a strong marker of low income and high clinical need, and it changes patient out-of-pocket costs because full-benefit dual eligibles pay only small copays for Part D drugs.