User Guide — Dual Eligible Beneficiaries Under Medicare and Medicaid
"Dual eligible beneficiaries" are patients who are eligible for both Medicare and Medicaid. These beneficiaries include people who are enrolled in Medicare Part A and/or Part B and who receive full Medicaid benefits and/or assistance with Medicare premiums or cost sharing through a Medicare Savings Program (MSP).
Note: For more information, see the CMS publication Dual Eligible Beneficiaries Under Medicare and Medicaid.
Patients with dual eligible plans have both Medicare and Medicaid benefits through a single commercial plan and have a single member ID to represent both plans.
Medicare-Medicaid Coordination Office
The Medicare-Medicaid Coordination Office was established pursuant to Section 2602 of the Affordable Care Act.
Note: The following text is taken from About the Medicare-Medicaid Coordination Office.
The goals of the Medicare-Medicaid Coordination Office are:
- Providing dual eligible individuals full access to the benefits to which such individuals are entitled under the Medicare and Medicaid programs.
- Simplifying the processes for dual eligible individuals to access the items and services they are entitled to under the Medicare and Medicaid programs.
- Improving the quality of health care and long-term services for dual eligible individuals.
- Increasing dual eligible individuals' understanding of and satisfaction with coverage under the Medicare and Medicaid programs.
- Eliminating regulatory conflicts between rules under the Medicare and Medicaid programs.
- Improving care continuity and ensuring safe and effective care transitions for dual eligible individuals.
- Eliminating cost-shifting between the Medicare and Medicaid programs and among related health care providers.
- Improving the quality of performance of providers of services and suppliers under the Medicare and Medicaid programs.
Determining whether a patient has a dual eligible plan
Not all plans for dual eligible beneficiaries clearly indicate that the plan is for dual eligible beneficiaries. In some cases, however, the primary insurance package listed on the Claim Action or Claim Edit page has the words "Dual Eligible" in the plan name.
Adjudication process for dual eligible plans
The claim should have only one "dual eligible" package selected on the Claim Action or Claim Edit page (no secondary package should exist). The claim is submitted to that single insurance, and we can expect adjudication from both Medicare and Medicaid for both portions of coverage.
- The Medicare portion includes the next responsible party (Medicaid) and the amounts that the Medicaid portion is expected to pay (copay, coinsurance, or deductible).
- The Medicaid portion generally includes the group code OA (Other Adjustment) and claim adjustment reason code 23 (that is, the normal expected secondary adjudication information).
Patients with dual eligible plans have both Medicare and Medicaid benefits through a single commercial plan and have a single member ID to represent both plans. Payers may send remittance to indicate the adjudication information for each portion of coverage (Medicare vs. Medicaid) in different ways.
- A single remittance that includes both the Medicare and Medicaid adjudication information.
- A first remittance that includes only the Medicare adjudication information, followed by a separate remittance that includes only the Medicaid adjudication information.