完全および部分的なデュアル適格性
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.
フルデュアル
“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.
メディケア部分給付デュアル
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).
パートBのみ
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.
注:フルデュアルがMedi-Calを失った場合(収入の増加や書類の欠落など)、MSPのみの評価を要求しない限り、自動的にパーシャルデュアルになることはありません。郡は、Medi-CalとMedicareの両方について毎年再決定を行います。メンバーがMedi-Calの資格を失い、特別なリクエストなしにMSPを保持する状況はありません。
メディケアパートAバイイン契約
2025年1月1日現在、カリフォルニア州はCMSとのバイイン契約に参加しており、Medi-CalはMedi-Calメンバーに対してMedicareパートAの保険料、共同保険、および控除額を自動的に支払います。
- 適格メディケア受益者(QMB)プログラムに登録されている
- 社会保障局(SSA)によって報告されたメディケアパートBの資格を持っている。
For more information about the Part A Buy-In policy, please see this Medicare Premium Payment (Buy-In) Program webpage.