Buo at Bahagyang Dual Eligibility
Bumalik sa Impormasyon para sa mga Matatanda
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.
Buong Duals
“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.
Mga Dalawahan ng Partial-Benefit ng Medicare
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).
Part B Lang
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.
Tandaan: Kung ang isang buong dual ay nawalan ng Medi-Cal (hal., dahil sa pagtaas ng kita o nawawalang papeles), hindi sila awtomatikong magiging partial dual, maliban kung humiling sila ng pagsusuri para sa MSP lamang. Ang mga county ay nagsasagawa ng taunang muling pagpapasiya para sa parehong Medi-Cal at Medicare. Walang sitwasyon kung saan mawawalan ng Kwalipikasyon sa Medi-Cal ang isang miyembro at panatilihin ang MSP nang walang espesyal na kahilingan.
Medicare Part A Buy-In Agreement
Simula noong Enero 1, 2025, ang Estado ng California ay lumahok sa isang buy-in na kasunduan sa CMS, kung saan awtomatikong binabayaran ng Medi-Cal ang mga premium, coinsurance, at deductible ng Medicare Part A para sa mga miyembro ng Medi-Cal na:
- Naka-enroll sa programang Qualified Medicare Beneficiary (QMB), at
- Magkaroon ng Medicare Part B entitlement gaya ng iniulat ng Social Security Administration (SSA).
For more information about the Part A Buy-In policy, please see this Medicare Premium Payment (Buy-In) Program webpage.
Additional Informational Resources
Mga Programa sa Pagtitipid ng Medicare sa California
Pinagsanib na Pangangalaga para sa Dalawang Kwalipikadong Benepisyaryo