Dual-Eligible Medicare Beneficiaries
- Participating Physician Groups (PPG)
Full-benefit dual-eligible beneficiaries include those individuals who have coverage under both Medicare and Medi-Cal. In accordance with Medicare guidelines, dual-eligible beneficiaries do not have coverage and access to all approved U.S. Food and Drug Administration (FDA) prescription medications and must enroll in a qualified Medicare prescription drug plan to receive prescription medication coverage. Dual-eligible beneficiaries automatically qualify for extra assistance and do not need to apply separately for the assistance.
Monthly prescription drug plan premiums, annual deductible and prescription drug copayment requirements depend on the beneficiary's annual income and resources, in accordance with the U.S. Department of Health and Human Services (HHS) Poverty Guidelines. Refer to the Centers for Medicare & Medicaid Services (CMS) for additional information regarding prescription drug copayments.
Beneficiaries with full-benefit dual-eligible status may voluntarily choose to enroll in a Medicare Part D plan, another Medicare Advantage (MA) health plan that offers prescription coverage, or a standalone prescription drug plan. Beneficiaries who do not enroll in a qualified Medicare prescription drug program are automatically enrolled in one to ensure there is no loss of prescription medication coverage. Full-benefit dual-eligible beneficiaries enrolled in the plan are enrolled in a Medicare prescription drug program offered by the same MA organization.
Full-benefit dual-eligible beneficiaries have additional opportunities to change plans.
Health Net, its contracted providers and their downstream entities are responsible for coordination and delivery of all dual special needs plan (D-SNP) patients’ Medicare and Medi-Cal benefits regardless of how the member receives their Medi-Cal benefits.
D-SNP members are those who are enrolled in:
- Wellcare By Health Net (Health Net) plans AND
- Medi-Cal benefits either through the state fee-for-service plan or a managed care plan (MCP) with any health plan.
These patients are NOT responsible for the coordination of their own Medi-Cal benefits.
If your D-SNP patient’s MA is through the Wellcare By Health Net (HMO D-SNP) plan but their Medi-Cal benefits are through another MCP, do not refer them to the DHCS for their Medi-Cal benefits or services not covered by Health Net.
D-SNP providers are responsible for identifying a member’s Medi-Cal MCP by checking the Department of Health Care Services (DHCS) Medi-Cal eligibility website. Refer to the Medi-Cal Automated Eligibility Verification (PDF) for steps on how to confirm MCP enrollment and care for your D-SNP patient.
If the member is enrolled in Health Net’s Medi-Cal plan, refer to the Medi-Cal Eligibility Verification section for more information.
Aligned Enrollment (EAE) D-SNP Members
Exclusively aligned enrollment is when members enroll in a dual eligible special needs plan (D-SNP) for Medicare benefits and in an Medi-Cal Managed Care Plan (MCP)for Medi-Cal benefits operated by the same parent organization for better care coordination and integration.
Exclusively aligned enrollment D-SNPs offer an integrated approach to care and care coordination. The matching Medicare D-SNP and Medi-Cal plans will work together to deliver all covered benefits.
As all members in the plan are also enrolled in the matching Medi-Cal MCP, they can receive integrated member materials, such as one integrated member ID card.
The exclusively aligned enrollment D-SNP plans will be:
- Wellcare By Health Net D-SNP with a Health Net Medi-Cal plan in Los Angeles, Sacramento, and Tulare counties.
- Wellcare By Health Net D-SNP with a CalViva Health Medi-Cal plan in Fresno, Kings, and Madera counties.
Full-Subsidy Eligible Beneficiaries and Enrollment
Other individuals who are full-subsidy eligible beneficiaries who may receive assistance include:
- Recipients of Full Benefit Dual Eligible (FBDE)
- Recipients of Medicare and Supplemental Security Income (SSI) only.
- Recipients of Medicare savings programs (MSPs), such as qualified Medicare beneficiaries (QMBs-plus), specified low-income Medicare beneficiaries (SLMBs-plus) or Qualifying Individuals.
MSP recipients receive additional assistance from the beneficiary's state of residence, which pays for Medicare premiums and/or cost-sharing.
The full-subsidy eligibles listed above automatically qualify for extra assistance and do not need to apply separately. These beneficiaries generally have slightly higher incomes than full-benefit dual-eligible beneficiaries, and Medicaid pays for cost-sharing associated with Medicare, including member premiums.
Low-Income Subsidy Eligibles
Beneficiaries with limited income and resources who do not fall into one of the subsidies described above may still qualify for assistance in paying for Medicare premiums and/or cost-sharing. These beneficiaries must apply for the low-income subsidy (LIS). Beneficiaries may apply for LIS by contacting the Social Security Administration or the state Medicaid office. Generally, the guidelines apply to incomes less than 150 percent of the federal poverty level (FPL) and limited assets. The type of income considered is based on the rules of the SSI program. Monthly prescription drug plan premium, annual deductible and prescription medication copayments depend on the beneficiary's annual income and resources, in accordance with the U.S. Department of Health and Human Services (HHS) Poverty Guidelines. Refer to the CMS for additional information regarding prescription medication copayments.
Beneficiaries with full-benefit dual-eligible status may voluntarily choose to enroll in a Medicare Part D plan, another health plan that offers prescription coverage, or a standalone prescription drug plan. Beneficiaries who do not enroll in a qualified Medicare prescription drug program are automatically enrolled in one to ensure there is no loss of prescription medication coverage. Full-benefit dual-eligible beneficiaries enrolled in the plan are enrolled in a Medicare prescription drug program offered by the same MA organization. CMS facilitates the enrollment.
Full-benefit dual-eligible beneficiaries may switch plans proving they have a valid election period to do so. Refer to the following sources for additional information.