This guidance replaces the original Dual Eligible guidance from October 6, 2016.
Brief Issue Description
This guidance explains how states are expected to report dual-eligible beneficiaries in the T-MSIS Eligible File.
Dual-eligible beneficiaries are individuals who receive both Medicare and Medicaid benefits. The two programs cover many of the same services, but Medicare pays first for the Medicare-covered services that are also covered by Medicaid. Medicaid covers services that Medicare does not cover, and these benefits are outlined in detail in this guidance.
An individual is eligible for Medicare if he or she is 65 or older, younger than 65 with disabilities, or has end-stage renal disease. There are four parts of Medicare coverage:
- Part A – Hospital insurance and associated costs
- Part B – Medical insurance (physician services, lab and x-ray services, outpatient and other services)
- Part C – Medicare Advantage Plan (offered privately)
- Part D – Prescription drug costs
All dual-eligible beneficiaries qualify for full Medicare benefits, but the level of benefits for which they are eligible under Medicaid can vary, generally depending on the beneficiary’s income and asset levels.
Dual-eligible beneficiaries (or “duals”) are enrolled in Medicare Part A and/or Part B, and in Medicaid (full benefits) and/or in Medicare Savings Programs (MSPs). MSPs cover costs such as Part A premiums and Part A and B deductibles, coinsurance, and copayments, depending on the program.
The dual-eligible population falls into two groups—“partial duals” and “full duals”—depending on the level of Medicaid benefits for which an individual is eligible. Because duals can typically account for a disproportionate share of both Medicare and Medicaid spending, researchers and policymakers often examine this population to better understand how to improve the delivery of care for these individuals whose health care needs can be quite diverse.
Partial duals are so called because Medicaid pays some of the expenses they incur under Medicare. These expenses include the premiums for Part B and for Part A, if applicable. Medicaid may also pay for some other cost-sharing amounts owed under Medicare, such as deductibles, coinsurance, and copayments. Partial duals qualify for these cost-sharing benefits from Medicaid if they are disabled and working, and if they have an income above the state’s full Medicaid threshold but below 125 percent of the federal poverty level (FPL), or 200 percent FPL. These partial duals are assigned the following codes in T-MSIS: DUAL-ELIGIBLE-CODE ‘01’ (Qualified Medicare Beneficiary [QMB] only), ‘03’ (Specified Low Income Medicare Beneficiary [SLMB] only), ‘05’ (Qualified Disabled and Working Individual [QDWI]), or ‘06’ (Qualifying Individual (QI]).
In addition to the benefits to which partial duals are entitled, full duals are entitled to Medicaid coverage for various health care services that Medicare does not cover, such as most types of long-term services and supports. Duals with lower income and asset levels fall into the full duals category and receive the full Medicaid benefits that their state offers. These full duals are assigned one of three codes in T-MSIS: DUAL-ELIGIBLE-CODE ‘02’ (QMB-plus), ‘04’ (SLMB-plus), or ‘08’ (Other full dual).
Duals can fall into several MSP categories that offer various benefits, impose certain restrictions, and differ based on income:
- QMB program. This program supports the payment of Medicare Part A, Part B premiums for individuals with an income of 100 percent FPL.
- QMB Plus. This group receives QMB benefits and full Medicaid benefits.
- Specified Low-Income Medicare Beneficiary (SLMB) program. This program supports the payment of Part B premiums for individuals with an income greater than 100 percent FPL but less than 120 FPL
- SLMB Plus. This group receives benefits from the SLMB program and full Medicaid benefits.
- Qualified Disabled Working Individual (QDWI) program. Individuals who lost their Medicare Part A coverage when they returned to work can buy back these benefits and have an income up to 200 percent FPL.
- Qualifying Individual (QI) program. This group receives Medicare Part A benefits and has an income of 120 percent FPL but less than 135 percent FPL. There is also an annual cap on the money available for this group.
- Pharmacy duals. Medicare Part D covers premiums, deductibles, and other cost sharing for prescription drugs up to a regional benchmark for all duals.
- “Other” duals. This group includes select cases such as medically needy beneficiaries in a nursing home who are not eligible for prescription drugs or individuals in a state’s Pharmacy Plus demonstration. States should use the code for this category only with CMS’s approval.
Medicaid income qualifications, covered benefits, and restrictions depend on the category into which a dual eligible falls. Please see Table 1 for further details on covered benefits for duals.
Table 1. Benefits covered by Medicaid
|Dual eligibility groups||Medicare Part A premiums
|Medicare Part B premiums||Co-insurance under Medicare Part A
and Part B
|Full Medicaid coverage|
States have been reporting dual status for many years in MSIS, and many of them generally have enough reliable information about beneficiaries who meet the criteria for the various dual classifications; however, with the transition to T-MSIS, some states are migrating their dual assignments to new systems. States might therefore need to review the processes through which they report duals in T-MSIS, such as how to report QMB or SLMB populations who are eligible only for premium or deductible payments from Medicaid. Other states might need clarification on how to use the broader classifications that include code 08 (Other dual eligible beneficiaries [Non QMB, SLMB, QDWI or QI], also known as other full duals), code 09 (Other), and code 10 (Separate CHIP Eligible is entitled to Medicare).
There are many dual eligible categories and as a consequence, many different codes required to report in T-MSIS depending on the categories a dual falls into. States may need clarification on which codes to use based on eligibility group. States may also need guidance on how to report with other eligibility segments, managed care plans, and Medicare premium payment reporting.
Detailed Reporting Expectations in T-MSIS
The State Medicare Modernization Act (MMA) Files of Dual Eligibles are considered to be reliable, current sources of information on the dual-eligible population. States submit these files monthly to CMS for purposes related to the administration of Medicare Part D benefits. Because the T-MSIS and MMA counts by dual code both count the same populations on a monthly basis, they are expected to be generally consistent. States can therefore consider these MMA files as a useful resource for validating dual code classifications in T-MSIS (see Appendix M, “Crosswalk of T-MSIS, MSIS and MMA Dual Eligible Code” in the T-MSIS Data Dictionary).
It is also important to remember the intent behind dual codes 08 and 09, which are broader dual categories, to ensure that they are being assigned correctly:
- DUAL-ELIGIBLE-CODE ‘08’ is intended to capture full duals who are not eligible for Medicaid as a QMB, SLMB, QDWI, or QI-1. Typically, these individuals need to spend down to qualify for Medicaid, or fall into a Medicaid eligibility poverty group that exceeds the limits established for other dual classifications. For full duals who can be distinguished separately, states, when possible, should not lump these duals into this code; and should instead assign them to one of the other full dual codes. The 08 code should be considered a catch-all for all remaining full duals.
- A small number of states have populations that do not necessarily fit neatly into one of the 01 to 08 codes. DUAL-ELIGIBLE-CODE ‘09’ is an alternative option for flagging these individuals as duals. Historically, very few states have used code 09 for participation in a state-specific program. For example, one state used it for medically needy beneficiaries in a nursing home who were not eligible for prescription drugs. Another state used code 09 with CMS’s permission to report the population in its Pharmacy Plus demonstration. It is not expected that many states will use this code, and assigning groups of eligible beneficiaries to code ‘09’ should only be done with CMS approval.
- States may use CHIP funds to create a Separate Title XXI CHIP program (S-CHIP), which lies outside of their Medicaid (Title XIX) program. Individuals enrolled in these programs differ from other beneficiaries in that they are not entitled to both Medicaid (Title XIX) and Medicare, but they are dually enrolled in both Separate CHIP and Medicare. The Separate CHIP population is now reported in T-MSIS. Since these beneficiaries are considered different than individuals enrolled under regular Medicaid, states should use DUAL-ELIGIBLE-CODE 10 in T-MSIS to flag individuals that are covered by both Separate CHIP and Medicare.
DUAL-ELIGIBLE-CODE ‘00’ should be used for Medicaid beneficiaries who are not enrolled in Medicare and are therefore not considered to be duals. Individuals covered by Separate CHIP, but not by Medicare, should also be reported to code 00.
- In the Eligible File, states should report DUAL-ELIGIBLE-CODE (ELG085, ELIGIBILITY-DETERMINANTS-ELG00005) and ELIGIBILITY-GROUP (ELG087, ELGIBILITY-DETERMINANTS-ELG00005) with the corresponding codes for each dual-eligible group (see Table 2).
Table 2. Dual-eligible categories and the Eligible File
Dual eligibility group DUAL-ELIGIBLE-CODE DUAL-ELIGIBLE-CODE Description ELIGIBILITY-GROUP Code QMB Only 01 Eligible is entitled to Medicare – QMB only 23 QMB Plus 02 Eligible is entitled to Medicare – QMB AND Medicaid coverage While QMB Plus beneficiaries meet the criteria for the QMB group, the record should be reported with the other eligibility group. The additional QMB benefits are identified through the dual code for QMB Plus. SLMB Only 03 Eligible is entitled to Medicare – SLMB only 25 SLMB Plus 04 Eligible is entitled to Medicare – SLMB AND Medicaid coverage While SLMB Plus beneficiaries meet the criteria for the SLMB group, the record should be reported with the other eligibility group. The additional SLMB benefits are identified through the dual code for SLMB Plus. QDWI 05 Eligible is entitled to Medicare – QDWI 24 QI 06 Eligible is entitled to Medicare – Qualifying individuals 26 Other Dual Eligible Beneficiaries 08 Eligible is entitled to Medicare – Other Dual Eligible Beneficiaries (Non QMB, SLMB, QDWI or QI) Not applicable Other[a] 09 Eligible is entitled to Medicare – Other (needs CMS approval) Not applicable Separate CHIP 10 Separate CHIP Eligible is entitled to Medicare Not applicable
[a] Other has been used in select cases, such as medically needy beneficiaries in a nursing home who are not eligible for prescription drugs or beneficiaries who are in a state’s Pharmacy Plus demonstration. This code should be used only with CMS’s approval.
- Partial duals are eligible for Medicaid, but they are only entitled to restricted benefits based on their Medicare dual-eligibility status (e.g., QMB, SLMB, QDWI, QI). In T-MSIS, states should report the restricted benefits with RESTRICTED-BENEFITS-CODE (ELG097, ELIGIBILITY-DETERMINANTS-ELG00005) = 3, and the dual-eligible status must indicate that the beneficiary is a partial dual eligible (DUAL-ELIGIBLE-CODE = “1” (QMB only), “3” (SLMB only), “5” (QDWI), or “6” (QI).
- States should report RESTRICTED-BENEFITS-CODE=5 when an individual is eligible for Medicaid or for Medicaid-Expansion CHIP, but for reasons other dual-eligibility status, is only entitled to restricted benefits (e.g., restricted benefits based on medically needy or other criteria).
Reporting Duals and Primary Eligibility Group
When reporting DUAL-ELIGIBLE-CODE, PRIMARY-ELIGIBILITY-GROUP-IND should always be set to “1” (Yes). The PRIMARY-ELIGIBILITY-GROUP-IND field is used to flag this eligibility segment as the key, or “primary,” eligibility classification that should be associated with a given person. Some state systems maintain records for individuals with who are in multiple eligibility groups that have overlapping periods of time. For any given time period that a person is eligible, only one eligibility segment should be assigned PRIMARY-ELIGIBILITY-GROUP-IND = “1” (Yes). The second eligibility segment (and any others) for the same period should be assigned “0” (No) to flag that it is not the primary eligibility group. DUAL-ELIGIBLE-CODE is considered to be the primary eligibility group classification for duals, so states should report this code as the primary eligibility classification, and they should set the other segments to “0”. States may assign different case numbers to each beneficiary’s Medicaid and Medicare eligibility, but only one case number can be in a segment that is flagged as the segment with the primary eligibility group value. States should report one segment for each case number, when applicable. For more information on eligibility segments, please see the Primary Eligibility Group Indicator guidance.
Reporting Dual-Eligible Beneficiaries and Managed Care
If a dual-eligible beneficiary is in Medicaid managed care or Medicare-Medicaid integrated care including PACE, D-SNPs, and Medicare-Medicaid Plans (MMPs), states should report the following data elements in the Managed-Care-Participation segment (MANAGED-CARE-PARTICIPATION-ELG00014) in the Eligible File:
- MANAGED-CARE-PLAN-ID (ELG192)
- MANAGED-CARE-PLAN-TYPE (ELG193)
- MANAGED-CARE-PLAN-ENROLLMENT-EFF-DATE (ELG196)
- MANAGED-CARE-PLAN-ENROLLMENT-END-DATE (ELG197)
Active segments can be end-dated according to instructions in the T-MSIS data dictionary.