全部及部分雙重資格
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.
全雙
“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.
聯邦醫療保險部分福利雙重保險
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).
僅限 B 部分
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.
注意：如果完全雙人失去 Medi-Cal（例如，由於收入增加或缺乏文書），則它們不會自動變成部分雙重，除非他們僅要求 MSP 評估。各縣對醫療保險和聯邦醫療保險進行年度重新決定。在沒有特別要求的情況下，會員不會失去 Medi-Cal 資格並保留 MSP。
聯邦醫療保險 A 部分購買協議
自 2025 年 1 月 1 日起，加利福尼亞州與 CMS 簽訂購協議，其中 Medi-Cal 會員自動支付醫療保險 A 部分保費、共同保險和免稅額：
- 已註冊合格的聯邦醫療保險受益人 (QMB) 計劃，以及
- 擁有社會保障管理局（SSA）報告的聯邦醫療保險 B 部分權利。
For more information about the Part A Buy-In policy, please see this Medicare Premium Payment (Buy-In) Program webpage.