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Full vs. partial dual eligibility — what’s the difference?
Posted: July 12, 2022
Last updated date: December 02, 2022
What does it mean to have full dual eligibility?
Dual eligible means that someone is eligible for both Medicaid and Medicare. To have full dual eligibility, it means you qualify for full state Medicaid benefits as well as for Medicare. A person who qualifies for full dual eligibility may also qualify for a Dual Special Needs plan (D-SNP).* This is a type of Medicare Advantage plan that offers extra benefits beyond traditional Medicare and Medicaid.
Medicare pays for most of the covered care and benefits, but Medicaid pays some out-of-pocket costs for copays, coinsurance, deductibles and premiums. Medicaid also covers benefits that aren’t covered by a Dual Special Needs Plan, such as long-term care.
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What does it mean to have partial dual eligibility?
Partial dual eligibility means a person qualifies for a Medicare Savings Program (MSP). MSPs are managed by the Medicaid program in each state. While MSPs cover certain Medicare costs, like Medicare Part A and Part B premiums, people with partial dual eligibility don’t receive full Medicaid medical benefits.
A person who qualifies for partial dual eligibility may also qualify for a Dual Special Needs plan (D-SNP).* While Medicare pays for most of the care and benefits covered, partial dual eligibles will be responsible for out-of-pocket costs.
How does a Medicare Savings Program (MSP) help partial dual eligibles?
When Medicare members get medical care, Medicare doesn’t cover the full amount of the services. The amount that’s left over, called cost share or out-of-pocket costs, is the Medicare member’s responsibility to pay. This may be known as a premium, copay, coinsurance or deductible. With MSPs, the state Medicaid program helps pay for some of these costs for partial dual eligibles. The amount of help (or cost sharing) Medicaid provides depends mainly on these 2 things:
- How much the person earns (income)
- How much they own (assets) — such as a house
For people who aren’t full dual eligibles, Medicaid may help cover some of the out-of-pocket costs for Medicare coverage
There are 4 different kinds of partial dual eligibility
The 4 partial dual eligibility categories are:
- Qualified Medicare Beneficiary (QMB)
The QMB program helps to pay premiums for Medicare Part A (hospital insurance) and Medicare Part B (medical insurance). Members who have QMB eligibility also get cost share coverage for copays, deductibles and coinsurance.
- Specified Low Income Medicare Beneficiary (SLMB)
The SLMB program helps to pay premiums for Medicare Part B (medical insurance) only.
- Qualified Individual (QI)
The QI program helps to pay premiums for Medicaid Part B (medical insurance), but these members individuals can have higher income than with SLMB.
- Qualified Disabled and Working Individuals (QDWI)
The QDWI program helps to pay Medicare Part A (hospital insurance) premiums. This for people who are disabled but have returned to work. As a result, they’ve lost their premium-free Medicare Part A coverage.
Get help to find a dual eligible health plan
Do you think you, a family member or someone you’re a caregiver for qualifies as a full or partial dual eligible? You can use the search field below to see what plans are available in your area. If you’re not sure, give us a call and talk with one of our licensed agents. They’ll explain all the choices and help you find the right dual-eligible health plan for you.
Call 1-844-812-5967, TTY: 711
8 a.m. - 8 p.m. local time, 7 days a week. Se habla español.
*Coverage for people who qualify for partial dual eligibility is only available in certain areas.
See UnitedHealthcare plans in your area
Dual-eligible or Medicaid plan benefits can change depending on where you live. Search using your ZIP code to find the right plan to meet your health care needs.