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Dual Eligibility and Medicare Open Enrollment

Dual Eligibility - Qualifying for Both Medicare and Medicaid
by Don Drake, Connelly Law Offices, Ltd.
Southern New England's Certified Elder Law Attorney
Attorney RJ Connelly III

"As most people know by now, based on the never-ending television ads with the likes of Joe Namath and Jimmy Walker, we are in the open enrollment period for Medicare," said certified elder law Attorney RJ Connelly III. "We have discussed this in a couple of previous blogs where we did an overview of the process and looked at the so-called donut whole of medication coverage. In today's blog, we want to discuss those individuals who are dual-eligible, meaning they qualify for a blended type of insurance with both Medicare and Medicaid. We will start by providing an overview of these insurances. "

Medicare

Medicare is health insurance for people sixty-five or older, certain people under sixty-five with disabilities, and people of any age with End-Stage Renal Disease. Medicare consists of four distinct parts:

  • Part A – Hospital Insurance (inpatient hospital care, inpatient care in a Skilled Nursing Facility, hospice care, and some home health services);

  • Part B – Medical Insurance (physician services, outpatient care, durable medical equipment, home health services, and many preventive services);

  • Part C – Medicare Advantage (MA) (Medicare-approved private insurance companies provide all Part A and Part B services and may provide prescription drug coverage and other supplemental benefits); and

  • Part D – The Prescription Drug Benefit (Medicare-approved private companies provide outpatient prescription drug coverage).

Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help Program, which helps pay for monthly premiums, annual deductibles, and co-payments.

Medicaid

The Medicaid Program is a joint venture funded at the Federal and State levels that pays for medical care for families and certain individuals with low incomes and/or limited resources. The Federal Government established guidelines that allow each state to:

  • Establish its own eligibility standards.

  • Determine the type, amount, length, and scope of services.

  • Establish rates of payment for services.

  • Oversee its own program.

Therefore, those who apply for Medicaid to assist with nursing home costs must be incredibly careful in meeting the requirements and often require an elder law attorney's help as each state has different guidelines around qualifications. For instance, the Medicaid laws in Rhode Island, Massachusetts, and Connecticut are the same in some areas but different in others which is why navigating the Medicaid minefield may require professional assistance as one mistake on the application could result in a rejection and a loss of assets.

Southern New England's Certified Elder Law Attorney

Dual Eligible Beneficiaries

“Dual Eligible Beneficiaries” is the term that describes individuals who are enrolled in both Medicare and Medicaid. Individuals must separately qualify for both Medicare and Medicaid coverage to become dual-eligible beneficiaries. "Roughly half of the dual eligibles first qualify for Medicare based on disability, compared with 17 percent of Medicare beneficiaries who are not dual eligibles, and about half qualify when they turn 65," said Attorney Connelly.


Medicaid’s eligibility rules vary across states, as we indicated earlier, but most dual eligibles qualify because they receive Supplemental Security Income (SSI) benefits, need nursing home care, have other high medical expenses, or meet the eligibility criteria for the Medicare Savings Programs (MSP) categories. These categories are as follows:

Now, this alphabet soup of programs comes with several qualifiers and disqualifiers. Rather than get into this, we provided a link to each program above that can explain each one of these much better than we could in a blog format.


There is also a Dual Eligible Special Needs Plan. This plan is a special type of Medicare Advantage plan that is individually designed to provide specialized benefits, provider networks, and medications/pharmacies to meet the unique needs of the individual.


To be eligible for the Special Needs plan, the individual must:

  • Be eligible for both Medicare and Medicaid.

  • Live in a service area of a Dual eligibility Special Needs plan.

  • Not have end-stage renal disease (unless a waiver is granted).

Southern New England's Certified Elder Law Attorney

Enrollment Periods

Unlike others on Medicare, dual-eligible individuals have much more flexibility to make changes to their Medicare coverage throughout the year. If someone is dual eligible, there is a Special Enrollment Period available on an ongoing basis which can be used to:

  • Switch from Original Medicare to a Medicaid Advantage plan

  • Switch Medicare Advantage plans.

  • Disenroll from a Medicare Advantage plan and return to original Medicare.

An individual who is dual eligible can use this Special Enrollment Period to enroll in, switch, or disenroll from a Dual Eligible Special Needs plan at any time. For instance, if an individual loses their Medicaid eligibility, they get a Special Enrollment Period that allows them to switch to a Medicare Advantage plan or return to Original Medicare. This special period starts the month the individual receives notice that they are no longer eligible for Medicaid services plus an additional two months. If an individual receives notice that they will lose Medicaid eligibility for the upcoming year, they can make these changes from January 1 to March 31.


Got all that? We know, quite confusing but information that those working in senior care facilities need to know and for those with senior family members who may be enrolling in Medicare for the first time or thinking about changing plans.


If you are confused as to whether a senior or someone with a disability qualifies for these services, click on our link below to go to a government site that can tell you what programs you may or may not qualify for.


Who Pays What?