واجد شرایط بودن دوگانه کامل و جزئی
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Individuals dually eligible for both Medicare and Medi-Cal are known as “dual eligibles” or “Medi-Medis.” The population of dual eligibles in California includes key groups below.
دوگانه کامل
“Full duals” are members who are enrolled in Medicare Parts A, B, and D, and Medi-Cal. Almost all of the 1.7 million dual eligible members in California are enrolled as full duals. Since these members are enrolled in Medicare Parts A and B, they may enroll in Medicare Advantage plans (including Dual Eligible Special Needs Plans, or D-SNPs). Full duals are entitled to full-scope Medi-Cal benefits, including coverage for Medicare cost sharing such as Medicare premiums and copays. Additionally, Medi-Cal covers benefits not provided by Medicare, such as long-term services and supports, dental and vision. Full duals are enrolled in Medi-Cal managed care plans. Medicare providers may not bill full duals for Medicare Parts A and B cost sharing.
Medicare با مزایای جزئی دوگانه
The federal Centers for Medicare &Medicaid Services (CMS) defines partial-benefit duals or “partial duals” as members enrolled in one of several Medicare Savings Programs (MSPs), with Part A and/or Part B coverage, but not enrolled in Medi-Cal. MSP enrollment for this group means that DHCS covers their Part A and/or Part B cost sharing, but they are not enrolled in Medi-Cal and do not receive full Medi-Cal benefits. Partial-benefit duals with Part A and B coverage, but not Medi-Cal coverage, are eligible to enroll in Medicare Advantage plans but not D-SNPs. These members are not enrolled in Medi-Cal managed care plans. Partial duals can be in QMB, SLMB, and QI, but are not QMB+, SLMB+, or full-benefit dual. In California there are relatively few partial-benefit duals, as the income limit for most MSPs in California is similar to the Medi-Cal income limit, and most individuals enrolling in MSPs also choose to also enroll in Medi-Cal and get full benefits. Medicare providers may not bill partial-benefit duals for Medicare Part A and B cost sharing. Individuals may apply for what they want (either Medi-Cal + Medicare Saving Program (MSP) or just MSP).
فقط قسمت B
Part B only includes members enrolled in Medicare Part B only (but not Part A) and Medi-Cal. The Part A Buy-In policy transitioned most of these members to full duals as of January 1, 2025. The remaining Part B only members includes those not QMB eligible. Members with Medicare Part B only and Medi-Cal are enrolled in Medi-Cal managed care plans. Medicare providers may not bill Part B only members with Medi-Cal for Medicare Part B cost sharing.
توجه: اگر یک دوتایی کامل Medi-Cal را از دست بدهد (مثلاً به دلیل افزایش درآمد یا کمبود مدارک)، آنها به طور خودکار به دوگانه جزئی تبدیل نمی شوند، مگر اینکه فقط برای MSP درخواست ارزیابی کرده باشند. بخشها سالانه یک تعیین مجدد برای Medi-Cal و Medicare انجام میدهند. هیچ موقعیتی وجود ندارد که عضوی واجد شرایط Medi-Cal را از دست بدهد و MSP را بدون درخواست خاصی حفظ کند.
قرارداد خرید Medicare Part A
از ژانویه 1 ، 2025 ، ایالت کالیفرنیا در یک قرارداد خرید با CMS شرکت می کند، به موجب آن Medi-Cal به طور خودکار حق بیمه، بیمه مشترک، و فرانشیزهای Medicare Part A را برای اعضای Medi-Cal می پردازد که:
- در برنامه Qualified Medicare Beneficiary (QMB) ثبت نام کرده اند و
- همانطور که توسط اداره تامین اجتماعی (SSA) گزارش شده است، از حق مدیکر قسمت B برخوردار باشید.
For more information about the Part A Buy-In policy, please see this Medicare Premium Payment (Buy-In) Program webpage.