Dual Eligible Beneficiaries

Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing. They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B and one of the following Medicaid Programs:

• Full Medicaid; or
• Special Need Plans, which include the following four programs:
○ Qualified Medicare Beneficiary (QMB) Program;
○ Specified Low-Income Medicare Beneficiary (SLMB) Program;
○ Qualifying Individual (QI) Program; and
○ Qualified Disabled Working Individual (QDWI) Program.

Dual eligible beneficiaries may choose coverage under FFS Medicare or a MA Plan. Medicare-covered services are paid first by Medicare because Medicaid is always
the payer of last resort. Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover

Full Medicaid

Its coverage either categorically or throught optional coverage groups based on medically need status. Special income levels for institutionalized individuals or home and community based waivers

Medicaid pays for part A and part B premiums and cost sharing for Medicare providers to the extent consistent with Medicaid state plan

QMB Only

Medicaid pays for part A AND Part B premiums, deductibles, coinsurance and copayments for Medicare services furnished by Medicare providers to the extent consisten with Medicaid state plan

• Medicaid pays for Part B premiums

Prohibited Billing
Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full. You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services. You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).

We could only bill patient if they SLMB plan.