How to Help Dual-Eligible Patients Find the Right Medicare or Medicaid Plan

Inside: Many patients are eligible to enroll in Medicare and Medicaid, but they don’t know what plan is best for them. Learn how to help your dual-eligible patients find the plan that fits them best. 

For many of your patients aged 65 and older, the Medicare annual enrollment period from October 15 to December 7 is the make or break time to make decisions about their healthcare for the coming year.

But a smaller category of your patients is playing by a different set of rules. These are patients that are not only eligible for Medicare, but Medicaid as well.

Dual-eligible patients, as they are known, have additional benefits available to them and qualify for special enrollment periods outside of the standard annual enrollment period. As a community pharmacist, you have an opportunity to retain patients by reaching out to dual-eligible patients year-round to educate them on their options.

Who is dually eligible?

Before we break down how dual-eligible patients receive can receive Medicare and Medicaid benefits, here’s a reminder of how Medicare works:

  • Medicare Part A provides insurance for hospitals, including inpatient care at hospitals and skilled nursing facilities, hospice care, and some home health services.
  • Medicare Part B provides medical insurance, like visits to physicians, outpatient hospital care, durable medical equipment, more home health services, and preventive care.
  • Medicare Part C is more commonly known as Medicare Advantage. Under this part of Medicare, private insurance companies cover the same services as Medicare Parts A and B, and could also cover prescription drugs and other supplemental benefits.
  • Medicare Part D is prescription drug coverage, covered by a Medicare-approved private company.

Together, Medicare Part A and B are often known as “Original Medicare,” and patients must join a standalone Part D plan to get prescription drug coverage. Patients who enroll in Medicare Advantage plans typically get Part D coverage along with Part A and Part B services.

Everyone over the age of 65 is eligible for Medicare, along with some people with disabilities under the age of 65, and people with end-stage renal disease.

On the other hand, Medicaid eligibility requirements aren’t as straightforward. While the federal government sets rules and regulations, states operate their own programs and can set their own eligibility standard. States also determine the payment rates and scope of services offered.

Broadly speaking, Medicaid is available to low-income individuals and families.

Dually eligible beneficiaries who are enrolled in both Medicare and Medicaid fall into one of four programs:

  • Qualified Medicare Beneficiary Program: Offers assistance paying premiums, deductibles, coinsurance, and copayments for Part A, Part B, or both.
  • Specified Low-Income Medicare Beneficiary Program: Offers assistance paying Part B premiums.
  • Qualifying Individual Program: Offers assistance paying Part B premiums on a limited first-come, first-serve basis.
  • Qualified Disabled Working Individual Program: This program is for some disabled and working beneficiaries under the age of 65 who are not eligible for Medicaid but meet income limitations set by the state. This program covers Part A premiums.

For dually eligible beneficiaries, Medicare is the first line of defense, and Medicaid steps in to cover the costs that Medicare doesn’t cover (or doesn’t completely cover). For more information about how coverage for dual-eligible patients works, and who exactly is qualified, visit the Center for Medicare and Medicaid Services.

Enrolling as a dual-eligible patient

Patients who are dually eligible for Medicare and Medicaid have more options for enrollment than typical Medicare patients. In addition to being able to enroll in a plan during the fall annual enrollment period, they can also switch their plan once a quarter, a total of four times a year.

Dual-eligible patients also commonly qualify for what’s known as a “benchmark” Part D plan, which are usually a more cost-effective option than standard Part D plans. As you help your pharmacy patients compare plans, focusing in on benchmark plans will help reduce their healthcare costs.

If patients don’t select a plan for themselves, they will be automatically enrolled in a benchmark plan if they qualify. However, they are often targeted by brokers advertising insurance plans with deceptive materials that look like they could be from a government source.

Patients who are swayed by these advertisements and select a plan that doesn’t have benchmark status won’t be automatically enrolled. This means they could end up paying higher premiums than necessary.

To navigate the sea of care options, many dual-eligible patients can benefit from the expertise of a trusted healthcare professional — like their community pharmacist — to find the plan that is the best for them.

Building relationships with dual-eligible patients

Medicare enrollment is overwhelming — a recent New York Times story reported that 71 percent of patients didn’t compare plans during enrollment — and for dual-eligible patients who have even more options, the process can be especially daunting.

Community pharmacists can step in to provide much-needed clarity during enrollment periods by educating patients on their options.

Software like FDS Amplicare Match can help you identify patients who are dually eligible for Medicare and Medicaid and help them choose a plan that works for you — and helps your pharmacy.

Patients who are already on benchmark plans with no premiums won’t have to worry about costs, but they could be on a plan that offers better benefits, like fewer formulary restrictions or prior authorization requirements. Sit down with patients and ask them about their current prescriptions and other medical conditions in order to select a plan that is tailored to their needs.

As you assist patients in finding a plan that helps them achieve better health outcomes, you can also steer them toward plans that will create better outcomes for your pharmacy. Certain plans, like non-preferred plans, will result in lower DIR fees for your pharmacy, but it makes no difference to the patient since they have no copays regardless.

Because dual-eligible patients can change their plan multiple times a year, you can focus your outreach efforts beyond Medicare’s annual enrollment period in the fall. Every quarter, reach out to eligible patients to explain how the special enrollment period works and offer consultations for patients who are unhappy with their current coverage.

Offering plan comparisons at your pharmacy doesn’t only help improve outcomes all around, it can foster patient loyalty. When you sit down and talk with patients about their care needs, you build a personal relationship with them.

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