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Avoid Common Dual-Eligible Reimbursement Mistakes

By Julia Leo

Dual-eligible beneficiaries qualify for coverage under both the federal Medicare program as well as their state Medicaid programs. These beneficiaries face a variety of healthcare issues and many require long-term care for chronic illnesses or severe disabilities. Coordinating their care under both the Medicare and Medicaid programs can be difficult. Due to inefficient coordination and misalignment of the programs, dual-eligible beneficiaries sometimes receive fragmented care – often resulting in repeat or unnecessary services.

Providers tasked with caring for dual-eligible beneficiaries face several potential issues, including coordination of care challenges, as well as confusing cost-sharing rules between the Medicare and Medicaid programs. Providers who treat dual-eligible beneficiaries should be aware of the issues surrounding this class of beneficiary – specifically, developments in the integration of care between the Medicare and Medicaid programs, as well as common payment issues and prohibitions providers are subject to.

Common Characteristics of Dual-Eligible Beneficiaries
First, we must understand how patients qualify for both programs and how the needs of those beneficiaries affect the Medicare and Medicaid budgets. In order to qualify for Medicare, generally, beneficiaries must be at least 65 years old or they must qualify for Social Security disability insurance.

People with serious illnesses and disabilities, such as end-stage renal disease or mental or cognitive disabilities, or those who require a kidney transplant, are also eligible for Medicare, regardless of their age at the time.1 On the other hand, state Medicaid programs generally offer coverage to low-income individuals based on need. Each state has the authority to define which individuals qualify for that state's Medicaid coverage and what medical services will be covered.2 As a result, coverage can vary greatly from state to state.

Some dual-eligible beneficiaries receive full benefits from both programs – these beneficiaries are referred to as "full duals."3 "Partial duals" are defined by the Congressional Budget Office (CBO) as people who receive full Medicare benefits but do not receive full coverage from their state Medicaid program.4 Partial duals may only qualify for a portion of their state Medicaid program or may only qualify for Medicaid assistance with their Medicare cost-sharing responsibilities.

Dual-eligible beneficiaries can generally be characterized as falling into one, or both, of the following categories: (a) they usually have at least one, if not multiple, chronic illnesses or disabilities and (b) they are usually low-income individuals, minorities, and/or female.5 The occurrence of serious health issues, such as diabetes, end-stage renal disease, depression, and cognitive or mental disabilities, is significantly higher for dual-eligible beneficiaries than for those individuals who qualify for only Medicare or Medicaid.6 More than half of the individuals considered full duals in 2009 qualified for Medicare due to a severe disability, rather than age.7 As stated by the CBO, "Disabled Medicare beneficiaries were more than three times as likely as elderly Medicare beneficiaries to be full duals."8

In addition to the staggering health issues faced by dual-eligible beneficiaries, it is estimated that 86 percent of dual-eligible beneficiaries are below 150 percent of the federal poverty level.9 Furthermore, according to the CBO's 2009 statistics, dual-eligible beneficiaries were represented largely by women and minorities. Women comprised approximately 62 percent of the full duals receiving care in 2009 and approximately 61 percent of partial duals.10 African-Americans and Hispanics comprised approximately 28 percent of full duals for the same year, with the same groups comprising 26 percent of the partial duals.11

The wide variance of reasons for qualifying as a dual-eligible beneficiary serves to demonstrate the infeasibility of developing streamlined plans of care for these individuals. Low-income people who qualify for Medicare based on an illness or disability rather than age may require far more extensive care than an aged beneficiary who qualifies for Medicaid based on their lower income in retirement. It is impossible to design a "one-size-fits-all" plan for treating dual-eligible beneficiaries. That fact only intensifies the myriad issues posed by coordinating care for these beneficiaries across the Medicare and Medicaid programs.

Fractured Care for Dual-Eligible Beneficiaries
In 2009, approximately nine million people qualified as dual-eligible beneficiaries.12 Seven million of those individuals were considered full duals, with the remaining two million considered partial duals. Designing coordinated care for these individuals – who often have more than one chronic condition – while they are being covered (in part or in full) by two different government healthcare programs is no simple task. It is easy for care to become fragmented due to the differences in coverage between Medicare and the Medicaid programs.

To see where the issues arise, you have to first understand the differences in care covered by each program. Medicare is generally considered the primary payor for acute care and postacute care services, including inpatient and outpatient hospital services, physician's services, and skilled nursing facilities or home healthcare.13 Medicare is also the primary payor for prescription drugs. Medicaid is generally the primary payor for long-term services and supports (LTSS), including nursing homes, hospice care, and home healthcare.14 Medicaid also covers, in some instances, healthcare that is never covered by Medicare, such as dental and vision. Due to the differences in each state's Medicaid program, coverages will vary from state to state.

It is clear from the general division of services that for the types of healthcare issues facing both full and partial dual-eligible beneficiaries, both programs will inevitably be treating beneficiaries for the same illness or disability. Dual-eligible beneficiaries are forced to navigate both the Medicare and Medicaid systems for coverage of related illnesses because treatment for one aspect of an illness is covered by one program, whereas treatment for another aspect is covered by the other.15 One study has shown that, due to the general lack of coordination between the programs, dual-eligible beneficiaries end up repeating hospital visits due to the poor quality of care.16 Duplicative and unnecessary services are provided and as a result, dual-eligible beneficiaries are the most costly patient population in the government healthcare system.

Given the growing costs associated with caring for dual-eligible beneficiaries, the Centers for Medicare & Medicaid Services (CMS) and several state Medicaid programs have begun developing methods for better integrating their care – and cutting the growing costs.17 Under the authority of the Affordable Care Act, CMS began launching "demonstrations" with certain state Medicaid programs designed to better align the costs of caring for these individuals, as well as integrating their care between the Medicare and Medicaid programs.18 CMS began testing different models with states to better align the financing of the two programs and to integrate primary, acute, behavioral health, and LTSS care for dual-eligible beneficiaries. Currently, 11 states have entered into a financial alignment demonstration project with CMS.19 One state, Minnesota, has begun a separate administrative alignment demonstration project.20 Several other states' proposed demonstration projects are still pending approval by CMS.

The outcome of these demonstration projects, and the experiences of each state Medicaid program, will have a great impact on how CMS and the state Medicaid programs move forward with containing costs and providing better, more effective care for dual-eligible beneficiaries. However, even with these recent efforts to better coordinate the Medicare and Medicaid programs and contain costs, providers still face several issues when it comes to obtaining reimbursement for services provided to dual-eligible beneficiaries.

Roadblocks and Common Mistakes for Dual-Eligible Healthcare
The following is an overview of the reimbursement issues that face providers of healthcare to dual-eligible beneficiaries.

Enrollment in the Applicable State Medicaid Program
Providers not enrolled in the state Medicaid program of a dual-eligible beneficiary for whom they provide medical services will not be able to collect reimbursement for the Medicaid-covered services provided to that dual-eligible beneficiary.21 CMS urges providers who treat dual-eligible beneficiaries to contact the applicable state Medicaid programs to determine the specific provider registration requirements for that state.22 State Medicaid programs may vary in terms of how they require providers to enroll with their program in order to start processing Medicaid claims for dual-eligible beneficiaries.

Understanding the Beneficiary's Coverage
One of the biggest reimbursement barriers for providers caring for dual-eligible beneficiaries is failing to have a full understanding of the dual-eligible beneficiary's coverage. This is where the difference between a full dual and partial dual becomes very important for providers. Generally, the type of services provided to the dual-eligible beneficiary will dictate which program will reimburse the provider.

For services that are covered by both Medicare and Medicaid, Medicare is always considered the primary payor.23 The state Medicaid program may pay for any difference in reimbursement amounts up to that state's program limit, but providers should remember that for services covered by both programs, Medicaid is considered "the payor of last resort."24 When a service is considered a Medicaid-only service, such as dental or vision services, Medicaid is the only form of reimbursement for the provider. Again, this will depend entirely on that state's Medicaid program coverage.

Special Health Plans for Dual-Eligible Individuals
Some dual-eligible individuals participate in dual-eligible special needs plans (D-SNP), such as the Qualified Medicare Beneficiary (QMB) Program, the Specified Low-Income Medicare Beneficiary (SLMB) Program, and the Qualified Disabled Working Individual (QDWI) Program.25 Each D-SNP is characterized by a different monthly income limit amount, and each program assists with a different combination of Medicare beneficiary costs. The QMB Program assists with Part A and Part B premiums, as well as deductibles, coinsurance, and copayments for dual-eligible beneficiaries. The SLMB Program assists dual-eligible beneficiaries with Part B premiums only. The QDWI Program assists dual-eligible beneficiaries with Part A premiums.

For QMBs specifically, providers must accept whatever payments they receive from Medicare and/or Medicaid as payment in full for services to the QMB.26 An individual must have been determined to be eligible for QMB status by their state Medicaid program. If the individual is deemed eligible for QMB status, the state Medicaid program will take over payments for any Medicare deductibles, coinsurance, and copayments. As such, any attempt to bill a QMB for Medicare cost-sharing expenses could result in sanctions for the provider.27 The provider must accept the amount that the state Medicaid program pays for the QMB, even if the state Medicaid program pays nothing. Additionally, if the provider is not enrolled with the state Medicaid program that provides coverage for the QMB, the provider will not be able to obtain reimbursement for the Medicare cost-sharing.

Looking Ahead
Providers who treat dual-eligible beneficiaries are faced with many challenges. They must provide the best care possible for beneficiaries who are bounced from one government program to another – and they must do so while also staying mindful of each beneficiary's level of coverage. Finally, providers need to know how to navigate both systems in order to ensure that they receive their full reimbursement for services provided to the beneficiary.

Hopefully, the demonstration projects currently being run by CMS and the state Medicaid programs will develop ways to simplify the complicated system through which dual-eligible beneficiaries receive their benefits. Coordination of care not only benefits the patient, it benefits the government programs paying for these services by cutting costs. However, until that simplification occurs, providers should stay updated on any changes in benefits or coverage for dual-eligible beneficiaries and should maintain proper enrollment in the programs from which the providers will be seeking reimbursement.

Julia M. Leo, Esq., is the chief compliance officer of Advocate Radiology Billing & Reimbursement Specialists, a nationwide medical billing and practice management company specializing in radiology revenue cycle management. Leo is responsible for overseeing the compliance program at Advocate and assisting clients with compliance-related issues. Prior to joining Advocate, Leo spent four years practicing law on a variety of healthcare issues.

1 "Dual Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies," Congressional Budget Office, last modified March 27, 2014,

2 Gretchen Jacobson, Tricia Neuman, Anthony Damico. "Medicare's Role for Dual Eligible Beneficiaries." The Henry J. Kaiser Family Foundation (April 2012). Accessed February 20, 2015.

3 Ibid. at 1.

4 Ibid.

5 Katherine Young, Rachel Garfield, MaryBeth Musumeci, Lisa Clemans-Cope, Emily Lawton.
"Medicaid's Role for Dual Eligible Beneficiaries." The Henry J. Kaiser Family Foundation (August 2013). Accessed February 20, 2015.

6 Ibid.

7 Ibid. at 1.

8 Ibid.

9 Ibid. at 5.

10 Ibid. at 1.

11 Ibid.

12 Ibid.

13 Ibid.

14 Ibid.

15 "Financial Models to Support State Efforts to Integrate Care of Medicare-Medicaid Enrollees," Centers for Medicare & Medicaid Services, last modified March 28, 2014, Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Downloads/CMSFinancialModelsFrequentlyAskedQuestions.pdf.

16 H. Joanna Jiang, PhD; Lauren M. Wier, MPH; DEB Potter, MS; Jacqueline Burgess, MBA. "Potentially Preventable Hospitalizations Among Medicare-Medicaid Dual-Eligibles, 2008." Agency for Healthcare Policy and Research (September 2010). Accessed February 20, 2015.

17 MaryBeth Musumeci. "Financial and Administrative Alignment Demonstrations for Dual-Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS." The Henry J. Kaiser Family Foundation. (July 24, 2014). Accessed February 20, 2015.

18 J. Crowley, MB Musumeci, E. Reaves. "Development of the Financial Alignment Demonstrations for Dual Eligible Beneficiaries: Perspectives from National and State Disability Stakeholders." The Henry J. Kaiser Family Foundation. (July 2013). Accessed February 20, 2015.

19 Ibid. at 17.

20 Ibid.

21 "MLN Matters: Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)," Centers for Medicare & Medicaid Services, last modified March 28, 2014, Articles/downloads/SE1128.pdf.

22 Ibid.

23 "Seniors & Medicare and Medicaid Enrollees,", Accessed February 20, 2015.

24 "Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs," Centers for Medicare & Medicaid Services, last modified April 1, 2014, Medicare-Learning-Network-MLN/MLNProducts/downloads/ Medicare_Beneficiaries_Dual_Eligibles_At_a_Glance.pdf.

25 "Dual Eligible Special Needs Plans," Centers for Medicare & Medicaid Services, Accessed February 20, 2015.

26 Section 1902(c)(3)(B) of the Social Security Act.

27 Ibid. at 24.

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