Medicaid Assistance for Medicare Beneficiaries with Low Incomes

Two types of Medicaid coverage are available for Medicare beneficiaries with low incomes: 

• coverage of the full Medicaid benefit package and financial assistance with Medicare premiums and cost-share, and 
• financial assistance only with Medicare premiums and (in some cases) cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. . 

Eligibility for full Medicaid benefits and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. assistance: To receive full Medicaid benefits in addition to Medicare benefits, individuals must meet the state’s Medicaid eligibility criteria (see this chapter’s section on Medicaid eligibility). For these beneficiaries, Medicare is the primary payer for medical services. However, they also have access to additional benefits covered by their state Medicaid programs that Medicare does not. Often referred to as “dual eligibles“Dual eligibles” are individuals who are eligible for both the Medicare and the Medicaid programs, also called duals. ,” these beneficiaries may have full Medicaid benefits and assistance with Medicare costs (sometimes known as “full duals“Duals” are individuals who are eligible for both the Medicare and the Medicaid programs, also called dual eligibles. ”). 

Some Medicare beneficiaries qualify to have Medicaid pay some or all of their Medicare cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. (premiums, copays, coinsuranceA form of health care cost sharing in which a percentage of covered expenses must be paid by the insured. In contrast, a copayment is a specific dollar amount that must be paid for a specific service. , and deductibles) under the Medicare Savings ProgramsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. (MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. ). In addition, some states offer coverage for some Medicaid services but not full Medicaid coverage. And some states offer additional financial assistance with Medicare costs outside of the MSPPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. programs. Medicare beneficiaries who do not qualify for full Medicaid benefits and only receive help with Medicare costs are sometimes known as “partial duals“Duals” are individuals who are eligible for both the Medicare and the Medicaid programs, also called dual eligibles. .” 

Medicare Savings ProgramsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. : Medicare beneficiaries who are not eligible for full Medicaid benefits may qualify for one of three MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. . Under the MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. , Medicaid pays some or all of an individual's out-of-pocket Medicare costs, such as premiums, deductibles, and copayments. The level of assistance varies by the four categories of MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. , each with its own income and asset requirements (Figure 7-2). 

These categories are: 

• Qualified Medicare BeneficiariesThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. (QMB),   
• Specified Low-Income Medicare Beneficiary (SLMBSLMB eligibility extends to all Medicare beneficiaries with incomes between 100 percent and 120 percent of the federal poverty level and who meet a strict asset test. The state’s Medicaid program will then pay the Part B premium. ), 
• Qualifying Individual (QI), and  
• Qualified Disabled and Working Individuals (QDWIs). 

States may broaden eligibility for MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. by increasing asset limitsThe value of assets a person or family can have and still qualify for public assistance benefits. behind the set federal minimums. They can also eliminate the asset requirement altogether. Although MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. do not pay cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for Medicare Part D, people enrolled in MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. are also eligible for the Medicare Low-Income Subsidy program (LIS) program, also known as Extra Help (see also this chapter’s section on Prescription Drugs in Medicare). 

Figure 7-2: Medicaid Protections for Medicare Beneficiaries with Low Incomes 

Payment issues for Qualified Medicare BeneficiariesThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. (QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. ): Federal law bars Medicare providers from billing QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. for the difference between what they are paid and what they charge. This is a practice sometimes known as balance billingWhen a provider bills a patient for the difference between the provider’s charge and the amount paid by an insurer or Medicare. Medicare sets limits on the amount that a patient can be required to pay. or improper billing. The amount paid by Medicare and the state (if any) for health services provided to a QMB must be considered payment in full. Providers are also prohibited from billing QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. for Medicare cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. , including deductibles, coinsuranceA form of health care cost sharing in which a percentage of covered expenses must be paid by the insured. In contrast, a copayment is a specific dollar amount that must be paid for a specific service. , and copayments.  

A state may choose not to pay the full Medicare cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. if doing so would cause the full provider payment (i.e., Medicare payment and cost-share payment) to exceed what the state’s Medicaid program would pay for the same service. For example, if the Medicare rate for Medical Service A is $120 (which includes $100 paid by Medicare and a $20 patient co-pay), but the state Medicaid rate for Medicare Service A is $105, the state MSPPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. will only reimburse the provider $5 for the QMB patient’s co-pay for Medical Service A. The provider receives $105 (Medicare pays $100 and Medicaid pays only $5 of the $20 copay). The provider must accept the lower amount—$105 in this example—as payment in full for Medical Service A, even though they normally charge and receive $120 for a non-QMB patient. 

The prohibition on balance billingWhen a provider bills a patient for the difference between the provider’s charge and the amount paid by an insurer or Medicare. Medicare sets limits on the amount that a patient can be required to pay. of QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. , combined with this state payment option, has led providers to claim that they are not adequately reimbursed by Medicaid when providing services to QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. . Some providers continue to balance-bill beneficiaries to try to attain the full balance of the bill. This violates federal law and their provider agreement with CMS. Although both state and federal authorities have enforcement remedies available, they are rarely used. 

The lower payments, billing difficulties, and confusion about QMB program reimbursement may result in providers refusing to see QMB patients. Meanwhile, QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. may avoid seeking needed care out of fear of being improperly billed.