What Is Dual Eligibility For Medicare And Medicaid?

What Is Dual Eligibility For Medicare And Medicaid?

dual eligibility is a situation in which a person is both eligible for Medicare and for Medicaid. In such a case, the person may have Medicare as a secondary payer to Medicaid, meaning that Medicaid pays first and Medicare pays what Medicaid does not cover (called a Medicare “secondary payer”). For example, Medicaid may pay for one year of a person's nursing home care, and Medicare would then pay for the next year of nursing home care. Dual eligibility helps to ensure that a person's health care needs are met by both Medicare and Medicaid and that there is continuity of care.

Medicare secondary payer rules apply to the Medicare portion of such an individual's services. These rules are different than the regular Medicare rules that apply to Medicare-covered services. For example, Medicare pays first for skilled nursing facility (SNF) services covered under Medicare Part A, and Medicaid pays first for SNF services covered under Medicaid.

The rules are different for services covered under both Medicare Part A and Medicaid (called “medically necessary services”) and for services covered under Medicare Part B and Medicaid (called “medically necessary services”).

See dual eligibles and medicare for more information about dual eligibles, including information about Medicare as a secondary payer to Medicaid.

What is the effect of the Affordable Care Act on dual eligibles as a Medicare secondary payer?

Most dual eligibles are eligible for both Medicare and Medicaid because of their low income. Generally, the Affordable Care Act (ACA) expanded Medicaid eligibility to include all individuals under age 65 (except those who are institutionalized or otherwise exempt) with incomes below 133% of the federal poverty level (FPL). The ACA reduced the gap in eligibility between states that expanded Medicaid and those that did not.

Before the ACA was enacted, dual eligibles with incomes below 133% of the FPL were eligible for Medicaid, but not for premium-free Medicare Part A. As a result, the dual eligible would be covered by Medicare Part B and Medicaid, including for services covered under Medicare Part A and Medicaid (“medically necessary services”). The Affordable Care Act created a new category of dual eligible: individuals with incomes between 100% and 133% of the FPL who are eligible for Medicaid but not for premium-free Part A. Also, the ACA introduced various new coordination of care initiatives such as the delivery system reform federal demonstration project, payment reform and other initiatives to support coordination of care for dual eligibles.

As a result of these changes, dual eligibles with incomes between 100% and 133% of the FPL were eligible for premium-free Part A and generally were covered by Medicare Part B and Medicaid, including for services covered under Medicare Part A and Medicaid (“medically necessary services”).

the Affordable Care Act and medicare as a secondary payer

The Affordable Care Act changed the secondary payer rule so that individuals who are entitled to both Medicare and Medicaid are eligible for services covered under Medicare Part A and Medicare Part B, even if they are eligible for premium-free Medicare Part A. Therefore, dual eligibles are now covered by Medicare for medically necessary services covered under Medicare Part A and Medicare Part B, even if they are covered by premium-free Part A and do not have Part B coverage.

The ACA also changed the rules regarding Medicare as a secondary payer for services covered under Medicare Part B and Medicaid. Under the ACA, Medicare is no longer a secondary payer if the health care services are covered under Medicaid and not covered under Medicare Part B.

If a dual eligible is covered by premium-free Part A, the individual may have Part B coverage. If the individual does not have Medicare Part B coverage, the individual will be covered by Medicare as a secondary payer if the health care services are covered under Medicaid and not covered under Medicare Part B.

medicare as a secondary payer for dual eligibles with premium-free part a

The ACA changed the Medicare as a secondary payer rules for individuals who are dual eligibles with incomes between 100% and 133% of the FPL and who are covered by premium-free Part A, meaning that they do not have Medicare Part B coverage.

Medicare is no longer a secondary payer if the health care services are covered under Medicaid and not covered under Medicare Part B.

medicare as a secondary payer for dual eligibles with medicare part b

For dual eligibles with premium-free Part A and Part B coverage, Medicare is no longer a secondary payer if the health care services are covered under Medicaid and not covered under Medicare Part B. Under the ACA, Medicaid is primary and Medicare is secondary for these dual eligibles.

medicare as a secondary payer for dual eligibles without premium-free part a

Under the ACA, Medicaid is primary and Medicare is secondary for dual eligibles without premium-free Part A. Therefore, if a dual eligible is covered by premium-free Part A and Part B, he or she is not covered by Medicare for services covered under Medicaid and not covered under Medicare Part B.

medicare as a secondary payer for individuals eligible for medicaid and not premium-free part a

The Affordable Care Act changed the rules regarding Medicare as a secondary payer for services covered under Medicare Part B and Medicaid for individuals who are dual eligibles (not covered by premium-free Part A) and are eligible for Medicaid.

Medicare is no longer a secondary payer if the health care services are covered under Medicaid and not covered under Medicare Part B. Therefore, if an individual is eligible for Medicaid and not covered by premium-free Part A, Medicare is no longer a secondary payer.

effect of the affordable care act on medicare as a secondary payer

The Affordable Care Act (ACA) changes the rules regarding Medicare as a secondary payer for services covered under Medicare Part B and Medicaid for dual eligibles

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