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1. Dual Copay Assistance
2. Dual Copay
3. Dual Copay Meaning

61.9 million Americans are Medicare beneficiaries.¹ In 2019, more than 12 million Americans were dually eligible for Medicare and Medicaid and are enrolled in both programs.²

Beneficiaries who are eligible for this combination of coverage are sometimes called Medicare dual eligible.

A small Medicaid copay.) Medicare Remittance Advice notices clearly indicate if a beneficiary is a QMB and show the beneficiary’s deductible, copayment, and coinsurance cost-sharing is zero. If a provider bills a QMB for Medicare cost-sharing, or turns a bill over to collections, the provider. Dual copay Which is the term for when a patient pays a copayment for brand name drugs and a lower copayment for generic drugs? Usually take 30 seconds to receive a reply.

If you are dual eligible for Medicare and Medicaid, you may qualify for a special type of Medicare Advantage (Part C) plan called a Medicare Dual-Eligible Special Needs Plan (D-SNP).

In this guide, we detail how being dual eligible for Medicare and Medicaid can affect your coverage, costs and benefits.

Can you have Medicare and Medicaid at the same time?

Medicare and Medicaid are both public health insurance programs. If you are dual eligible, you can have both Medicare and Medicaid coverage at the same time.

Two of the key differences between Medicare vs. Medicaid include:

• Medicare is for people age 65 and over and for certain people under 65 who have a qualifying disability. Medicare eligibility is consistent for everyone across the U.S., no matter what state you live in.
  
• Medicaid is for people of any age who meet certain income qualifications. Medicaid is administered by state governments, and eligibility requirements can differ between states.

Who is dual eligible for Medicare and Medicaid?

To be Medicare dual eligible, you have to meet the requirements for Medicare and your state’s Medicaid program.

To be eligible for Medicare, you must:

• Be at least 65 years old or having a qualifying disability
• Be a U.S. citizen or permanent legal resident
• Be eligible for benefits through Social Security or the Railroad Retirement Board

Generally speaking, Medicaid provides health insurance to low-income individuals and families, children and pregnant women. The best way to find out if you are eligible for Medicaid is to visit your state’s Medicaid website.

If you're eligible for Medicaid and want to find out if you're also eligible for a dual-eligible Medicare Medicaid plan, you can all to speak with a licensed insurance to find out if you're eligible. An agent can help you compare the plans that are available where you live and find out what they may cover, which could include benefits like prescription drugs and other services.

Or call 1-800-557-60591-800-557-6059TTY Users: 711 24/7 to speak with a licensed insurance agent.

What type of coverage do you get if you are dual eligible for Medicare and Medicaid?

There are two levels of coverage for beneficiaries who are dual eligible:

• Full dual eligible
  Full dual eligible refers to those who receive full Medicaid benefits and are also enrolled in Medicare.
  People who are full dual eligible typically receive Supplemental Security Income (SSI) benefits, which provide cash assistance for basic food and housing needs.
  Qualifying as full dual eligible is based on your assets, which include checking and savings accounts, stocks, real estate (other than your primary residence) and vehicles (if you own more than one).
  
• Partial dual eligible
  Partial dual eligibility includes those who receive assistance from Medicaid in order to help pay for Medicare costs such as premiums, coinsurance or deductibles.
  Partial dual eligibles fall into one of four categories of eligibility for Medicare Savings Programs.

A Medicare Savings Program (MSP) is a federally funded program administered within each state that helps lower income people pay for Medicare premiums, deductibles, copayments and coinsurance.

The four Medicare Savings Programs are outlined below.

Qualified Medicare Beneficiary (QMB) Program

This program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance and copayments.

Eligibility requires:

• Income of no more than $1,061 per month for an individual in 2019, or $1,430 per month for a married couple
• Resources of no more than $7,730 for an individual in 2019, or $11,600 for a married couple

Specified Low-Income Medicare Beneficiary (SLMB) Program

The SLMB program helps pay for Medicare Part B premiums.

Eligibility requires:

• Income of no more than $1,269 per month for an individual in 2019, or $1,711 per month for a married couple
• Resources of no more than $7,730 for an individual in 2019, or $11,600 for a married couple

Qualifying Individual (QI) Program

Like the SLMB, the Qualifying Individual program helps pay for Part B premiums.

Eligibility requires:

• Income of no more than $1,426 per month for an individual in 2019, or $1,923 for a married couple
• Resources of no more than $7,730 for individuals in 2019, or $11,600 for married couples

Qualified Disabled Working Individual (QDWI) Program

The QDWI Program helps pay for the Medicare Part A premium for certain people who meet one of the following criteria:

• Have a disability but are still working
• Lost their premium-free Part A coverage when they returned to work
• Are not receiving medical assistance from their state
• Meet the income and resource limits below
  • Income of no more than $4,249 per month for an individual in 2019, or $5,722 for a married couple.
  • Resources of $4,000 for an individual in 2019, or $6,000 for a married couple.

The income and resource limits listed above may increase in 2020. If your income and resources are slightly higher, you should still apply.

Medicare Dual Eligible Special Needs Plans (D-SNPs)

Another type of coverage that may be available to dual eligible beneficiaries (depending on where you live) is a Medicare Dual Eligible Special Needs Plan (D-SNP).

A Medicare special needs plan is a certain type of Medicare Advantage plan that is designed for people with specific health conditions or circumstances.

A D-SNP is built for the specific needs of dual eligibles. All Medicare SNPs (including Medicare D-SNPs) provide prescription drug coverage.

How do Medicare and Medicaid work together?

For dual eligible beneficiaries, Medicare serves as the primary payer, and Medicaid acts as the secondary payer.

That means Medicare is the first to pay for covered services and items, and then Medicaid will help pay some or all of your remaining costs.

What is PACE for Medicare and Medicaid?

Another Medicare and Medicaid program is PACE, or Programs of All-Inclusive Care for the Elderly.

PACE helps older Medicare beneficiaries to seek health care within their community, in their home and at PACE facilities.

Some of the things that can be covered by PACE include:

• Adult day primary care
• Dental care
• Emergency services
• Home care
• Hospital care
• Lab and X-ray services
• Meals
• Medical specialty services
• Nursing home care
• Nutritional counseling
• Occupational therapy
• Physical therapy
• Prescription drugs
• Preventive care
• Respite care
• Social work counseling
• Caregiver training
• Transportation to a PACE facility when medically necessary

PACE is not strictly restricted to Medicare dual eligible beneficiaries. You may be eligible for PACE with only Medicare or only Medicaid (or both).

However, you must meet all of the following conditions:

• Be at least 55 years old
• Live in the service area of a PACE organization
• Require a nursing home-level of care
• Be able to live safely in the community with help from PACE

What is CHIP?

CHIP is a Medicaid program for children and stands for Children’s Health Insurance Program.

CHIP benefits vary by state, but they generally include EPSDT, or Early and Periodic Screening, Diagnostic and Treatment services. This coverage is designed to ensure children receive proper early detection and related care so that health problems may be averted or diagnosed as early as possible.

CHIP programs in all states must provide well-baby and well-child care, dental coverage, behavioral health care and vaccines.

CHIP serves uninsured children up to age 19 in families that earn too much money to qualify for Medicaid but still have trouble affording care.

What is Medicare Extra Help?

Extra Help is a federal program that helps pay for out-of-pocket costs related to Medicare prescription drug coverage. Extra Help is also known as the Medicare Part D Low-Income Subsidy (LIS)

The assistance that Medicare Extra Help may provide includes:

• Help paying Part D premiums
• Lowered out-of-pocket costs of prescription drugs
• An annual Special Enrollment Period to enroll in a Part D plan or switch to a new one
• Elimination of Part D late enrollment penalties

You automatically qualify for Extra Help if you are enrolled in Medicaid, Supplemental Security Income or a Medicare Savings Program.

You may still qualify for Extra Help if you are not enrolled in any of those programs but still have income and assets below a certain limit.

Find Medicare Dual-Eligible Special Needs Plans in your area

There may be Medicare D-SNPs available where you live, though they aren’t as widely available as other types of Medicare Advantage plans.

A licensed insurance agent can help you explore your Medicare Advantage plan options. Compare the plans that are available and find out what they may cover, which could include benefits like prescription drugs or dental care.

Find Medicare Advantage plans in your area

Or call 1-800-557-60591-800-557-6059TTY Users: 711 24/7 to speak with a licensed insurance agent.

UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) is a 2020 Medicare Advantage Special Needs Plan plan by UnitedHealthcare. This plan from UnitedHealthcare works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from UnitedHealthcare and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) DS-H0432 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.

2020 Medicare Special Needs Plan Details

The UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) DS-H0432 is available to residents in Alabama, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.

Part-C Premium

UnitedHealthcare plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

The UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) plan has a monthly drug premium of $15.30 and a $435.00 drug deductible. This UnitedHealthcare plan offers a $15.30 Part D Basic Premium that is below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by UnitedHealthcare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $15.30. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.

Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $3.80 for 75% low income subsidy $7.60 for 50% and $11.50 for 25%.

Gap Coverage

In 2020 once you and your plan provider have spent $4020 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA 'donut hole') You will be required to pay 25% for brand-name drugs and 25% on generic drugs unless your plan offers additional coverage. This UnitedHealthcare plan does not offer additional coverage through the gap.

UnitedHealthcare Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) H0432-009 Formulary here.

(*2020 Plan services will be added when available)

Health plan deductible

Emergency care/Urgent care

Diagnostic procedures/lab services/imaging

Hearing

Preventive dental

Comprehensive dental

Vision

Mental health services

Skilled Nursing Facility

Rehabilitation services

Ground ambulance

Other health plan deductibles?

Transportation

Foot care (podiatry services)

Medical equipment/supplies

Wellness programs (e.g., fitness, nursing hotline)

Medicare Part B drugs

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

Optional supplemental benefits

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

Inpatient hospital coverage

Dual Copay Assistance

Outpatient hospital coverage

Doctor visits

Preventive care

Ratings for UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) DS

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) Plans Performance

Health Plan Customer Service Rating for UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)

UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) Drug Plan Customer Service ratings

Dual Copay

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Coverage Area for UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)

Source: CMS.

Plans as of September 4, 2019.

Star Rating as of October 11, 2019.

Plan Services are 2019 information as reference. 2020 information will be added when released.

Notes: Data are subject to change. All contracts for 2020 have not been finalized. For 2020, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Dual Copay Meaning

Includes 2020 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.