Full Dual Eligible

[jolivertexas]

One of my clients logged into the Medicare website and checked on his Medicare enrollment status.

He was automatically enrolled in a Part D prescription plan and is receiving the LIS copays $2.65-$6.60

His subsidy is showing as dual eligible, however, he does not have a Medicaid card and he is paying the 20% when he goes to the doctor.

Would that mean that he is not really dual eligible? Is there an easy way to find this out without calling?

 

[honestagent]

Call. Just make the call. Don't come on here and ask that - because- there are a couple of different tiers of Medicaid where some are full and some are partial. And each state handles things differently. It's a state run program per state - per area -networks - etc. etc., it's just so messy. Just call Medicare with the client. You'll be really happy you did.

Sidenote: Just because they don't have a card doesn't mean they're not a full dual - or even if they have a card. And doctors' offices can screw up billing too. Call. Did I say make the call yet? :-)

 

[openmindedone]

Call. Just make the call. Don't come on here and ask that - because- there are a couple of different tiers of Medicaid where some are full and some are partial. And each state handles things differently. It's a state run program per state - per area -networks - etc. etc., it's just so messy. Just call Medicare with the client. You'll be really happy you did.

Sidenote: Just because they don't have a card doesn't mean they're not a full dual - or even if they have a card. And doctors' offices can screw up billing too. Call. Did I say make the call yet? :-)

Right on.

I will speculate that this person isn't dual eligible because the co-pays would be $1.15-$3.35 for meds.

 

[hunting101]

Even though he may be dual eligible it would appear that he DOES NOT have a med sup or Med Advantage Plan.

That is why he is paying 20% when he goes to doctor NO ONE is picking up his 20% of Part B costs or if he has a Med Advantage Plan his doctor does not accept Medicaid and client has to eat it.

If client can prove insurability put him on a Plan F or N

 

[jdeasy]

Probably a 100% LIS person and not a QMB plus. Also may be on medicaid and just doesn't have the card but the bills are being paid because the doctors are charging medicaid?

Could be an SLMB?

Did someone mention that you should call CMS with the person?

 

[midwestbroker]

Agreed on the call part. Providers cannot bill a full dual eligible, as it is against CMS regs. Anyone that is not QMB may be billed as they are only entitled to Part A or B premiums being paid, not co-insurance, cost sharing or deductibles.

This is from a CMS memo (MLN Matters Number SE1128):

All Medicare physicians, providers, and suppliers who offer services and supplies to QMBs must be aware that they may not bill QMBs for Medicare cost-sharing. This includes deductible, coinsurance, and copayments, known as “balance billing.” Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, prohibits Medicare providers from balance billing QMBs for Medicare cost-sharing. QMBs have no legal obligation to make further payment to a provider or Medicare managed care plan for Part A or Part B cost sharing. Providers who inappropriately bill QMBs for Medicare cost-sharing are subject to sanctions.