Module 2 - Medicare Advantage Plans and Dual Eligible Beneficiearies

Question 1

Beneficiaries who qualify for both Medicare and Medicaid are considered “dual eligible” individuals Dual eligible beneficiaries include beneficiaries enrolled in Medicare Part A and/ or Part B and receiving full Medicaid benefits and/or assistance with Medicare premiums or cost-sharing. The Medicaid programs that help beneficiaries pay for premiums for cost-sharing are also known as “Medicare Savings Programs.”

What are the general 4 categories that these programs fall under?

Answer 1

These programs generally fall under 4 categories:

1. The Qualified Medicare Beneficiary (QMB) program:
   
   • Helps pay premiums, deductibles, coinsurance, and copayments for Part A, Part B, or both programs.
2. The Specified Low-Income Medicare Beneficiary (SLMB) program:
   
   • helps pay Part B premiums.
3. The Qualifying Individual (QI) program:
   
   • Helps pay Part B premiums.
4. The Qualified Disabled Working Individual (QDWI) program:
   
   • pays the Part A premium for certain disabled and working beneficiaries.

Question 2

Qualified Medicare Beneficiaries (QMBs) fall into two categories:

Answer 2

1. QMB only: Those beneficiaries who just receive assistance paying for their Medicare premiums and cost-sharing.
2. QMB plus: Those beneficiaries who are also eligible for full Medicaid benefits.

Individuals who fall into other categories of Medicare Saving Programs may also be eligible for full Medicaid benefits. Such individuals, along with QMB plus individuals, are known as full-benefit dual eligible (FBDEs).

Question 3

What are the 2 special rules that apply to all QMBs?

Answer 3

1. When a QMB enrolls in an MA plan, the beneficiary does not have to pay more cost-sharing than any minimal copayment that would apply under Medicaid.
2. All providers (whether or not they are Medicaid participating, or in-network) are prohibited by law from balance billing QMBs for any Medicare cost-sharing amounts. Providers who balance bill are subject to sanctions.

Question 4

What are the 3 general characteristics of MA Plans and Dual Eligible Beneficiearies,

Answer 4

1. Dual eligible beneficiaries may enroll in any type of MA plan except an mA MSA.
2. Some MA plans, known as dual-eligible Special Needs Plans (D-SNPs), are tailored to dual-eligible individuals, depending on the category (i.e., QMB, QMB-Plus, SLMB, etc.) to which they belong.
3. Issues that are important to dual-eligible beneficiaries considering MA enrollment include:
   • Whether the beneficiary is eligible for medical benefits covered under Medicaid. Medicaid may cover items and services not covered by Medicare, but Medicaid will only pay for those items and services if they are furnished by Medicaid participating providers. (Note, however, that even providers NOT participating in Medicaid must hold beneficiaries.)

–Whether the beneficiary will need help to find providers who accept both Medicare and Medicaid to obtain any Medicaid benefits.

Question 5

Medicare Advantage Plans an Dual Eligible Beneficiaries Case Study:

Mr. Walsh is a Qualified Medicare Beneficiary (QMB). He enrolls in a Medicare Advantage HMO. Mr. Walsh goes to his primary care doctor to receive a Medicare covered service The normal copayment is $25.000.

Answer 5

The doctor may only collect from Mr. Walsh any minimal cost sharing allowable under the state Medicaid program which in Mr. Walsh’s case is $2.00 for his physician visit. His doctor may bill the state for the cost-sharing, but the hold harmless obligation applies regardless of whether or how much of the cost-sharing the state pays.