What is a dual eligible patient?

“Dual eligible beneficiaries” is the general term that describes individuals who are enrolled in both Medicare and Medicaid, or receive extra help through Social Security. The term includes individuals who are enrolled in Medicare Part A and/or Part B and receive full Medicaid benefits and/or assistance with Medicare premiums or cost sharing through one of the following “Medicare Savings Program” (MSP) categories:

  • Qualified Medicare Beneficiary (QMB) Program – Helps pay for Part A and/or Part B premiums, deductibles, coinsurance, and copayments;
  • Specified Low-Income Medicare Beneficiary (SLMB) Program – Helps pay for Part B premiums; 
  • Qualifying Individual (QI) Program – Helps pay for Part B premiums; and 
  • Qualified Disabled Working Individual (QDWI) Program – Pays the Part A premium for certain people who have disabilities and are working.

 This page here explains these different programs in detail. 

Dual eligible patients can switch their Medicare plan once every quarter between January and September which adds up to a total of three times per year. 

  • Q1: January-March
  • Q2: April-June
  • Q3: July-September

This Special Enrollment Period (SEP)  is considered “used” based on the month in which the patient enrolls in a plan. If the plan receives the enrollment in March (which would be effective April 1st), this counts as “using” the SEP for the 1st quarter, not the 2nd quarter.

Open enrollment (October 15th - December 7th) can be used to enroll in a new plan for the following year. 

While their copays are generally consistent across all plans due to their subsidy, there can be great variation in reimbursements across different plans, providing you with opportunities to increase revenue...

What's Next? 

Click here to learn why it's important to help your dual eligible patients review their Medicare plan options throughout the entire year!

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