Medicare dual eligible

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Medicare dual eligibles, in the Medicare system of the United States, are Medicare Part A and/or B recipients who either [1] qualify for a Medicare Savings Programs (MSP) or [2] qualify for Medicaid benefits. Dual eligibles generally qualify for the Qualified Medicare Beneficiary (QMB) benefits, in which Medicare Part A premiums, Medicare Part B premiums, and Medicare Deductibles, coinsurance, and copayments are covered by Medicaid, effectively providing full health care coverage.[1]

Historical context[edit]

With the advent of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, these dual eligibles have automatically been enrolled to a random Medicare Part D plan, effective January 1 of 2006.

As a result of this auto assignment, participants who were already enrolled in a Medicare Advantage HMO, may have been automatically disenrolled from their medical plan to allow for part D enrollment. Medicaid will still cover drugs for dual-eligible patients that are not covered by Medicare Part D, including certain controlled substances.


Pharmacies know by automation who these patients are.

Individuals that qualify for dual eligibility will be paid first by Medicare and the remainder will be paid by Medicaid.[2]

Section 231 of the Medicare Modernization Act of 2003 created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs called the Medicare Advantage Special Needs Plans (SNP) program.

"Special needs individuals" were identified by Congress as :

1) institutionalized

2) dually eligible; and/or

3) individuals with severe or disabling chronic conditions.

Delivery conditions[edit]

SNPs must offer care to the unique needs of low-income, chronically ill, and institutionalized Medicare beneficiaries. Given their expertise in serving these populations, many Medicaid managed care plans also offer SNPs to serve dual eligibles.[3]

A study looking at physician's views of Medicare Part D, and in particular how it pertains to dual-eligibles, found that many physicians expressed concern regarding access to prescription drugs, especially for dual-eligibles. Almost half of physicians responded that the access to prescription drugs for dual-eligibles was worse under Part D than relative to the previous Medicaid, and more than half (63%) reported higher administration burden.


Many physicians stated that dual-eligibles had less access under Part D than in three Medicaid restrictive states. This suggests that the transparency of Part D formulary coverage needs to be improved to improve access to these resources for physicians.[4]

A further study by the same group of researchers found that despite the above physicians' views on access to healthcare among dual-eligibles, there were no statistically significant changes in pharmaceutical utilization or out-of-pocket expenditures in the 18 months after Medicare Part D implementation.

When comparing a group of dual-eligibles (the experimental group) with a control group of near-elderly Medicaid-covered patients, both groups showed a decline in costs rights after the implementation of Part D, which then leveled off. The expenditures for both groups tracked each other.[5]


  1. ^ "Medicare_Beneficiaries Dual Eligibles At a Glance". DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Retrieved 12 July 2012. 
  2. ^ [1][dead link]
  3. ^ "Dual Eligible SNP (D-SNP)". Retrieved 12 July 2012. 
  4. ^ Epstein, AJ; Rathore, SS; Alexander, GC; Ketcham, JD (2008). "Primary care physicians' views of Medicare Part D". The American journal of managed care 14 (11 Suppl): SP5–13. PMID 18991482. [unreliable medical source?]
  5. ^ Basu, Anirban; Yin, Wesley; Alexander, G. Caleb (2010). "Impact of Medicare Part D on Medicare-Medicaid Dual-Eligible Beneficiaries' Prescription Utilization and Expenditures". Health Services Research 45 (1): 133–51. doi:10.1111/j.1475-6773.2009.01065.x. PMID 20002765. [unreliable medical source?]

External links[edit]