Beneciaries Dually Eligible for Medicare & Medicaid MLN Fact Sheet
Page 3 of 8 MLN006977 June 2024
Medicaid Program
Medicaid is a joint federal and state program that provides health insurance for certain people with
low income. Each state administers its own program, following broad national federal guidelines,
statutes, regulations, and policies. Each state:
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Establishes eligibility standards
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Decides type, amount, duration, and scope of services
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Sets payment rates
The Medicare Part D low income subsidy (LIS) program, also referred to as the Extra Help Program,
helps pay enrollees’ Medicare drug plan monthly premiums, annual deductibles, and copayments for
those who have or want Part D coverage and meet certain income and resource limits.
Dually Eligible Beneciaries
Dually eligible beneciaries are eligible for both Medicare and Medicaid. They include patients in
Medicare Part A, Part B, or both, and those getting full Medicaid benets or help with Medicare
premiums or cost-sharing through 1 of these Medicare Savings Program (MSP) eligibility groups:
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Qualied Medicare Beneciary (QMB): Covers Part A and Part B premiums, deductibles,
coinsurance, and copayments.
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Specied Low-Income Medicare Beneciary (SLMB): Covers only Part B premiums.
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Qualifying Individual (QI): Covers only Part B premiums (people enrolled in this program can’t
have any other Medicaid eligibility).
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Qualied Disabled Working Individual (QDWI): Covers only Part A premiums for certain
people under age 65 with disabilities who return to work. Medicare pays covered dually eligible
beneciaries’ medical services rst because Medicare is the primary payer for items and services
that both programs cover. Medicaid may cover medical costs that Medicare doesn’t cover or
partially covers (for example, nursing home care, personal care, and home- and community-
based services). Beneciaries’ coverage can vary by state. Some Medicaid programs pay for care
directly through Fee-for-Service (FFS) coverage. Others oer Medicaid through managed care or
other integrated care models.
Medicare providers can’t
bill QMB patients for Medicare cost-sharing. This includes deductibles,
coinsurance, and copayments. In some cases, a patient may owe a small Medicaid copayment.
Medicare and Medicaid payments (if any) (and any applicable Medicaid QMB copayment) are
considered payment in full. You’re subject to sanctions if you bill a QMB above the total Medicare
and Medicaid payments (even when Medicaid pays nothing).