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There are 10.8 million individuals enrolled in both Medicare and Medicaid across the country. All are low-income and most have high health care needs and face barriers in accessing the care they need. Explore the sections below to find Issue Briefs, Fact Sheets, and other resources to help you connect older adults to these programs, as well as advocacy tips and manuals to help you expand, improve, and protect the programs in your own community. If you’re looking for a specific resource you don’t see here, or would like to explore older resources, search our Resource Library.
Improper billing (also sometimes referred to as “balance billing”) occurs when doctors, hospitals, or other providers charge beneficiaries with both Medicaid and Medicare for co-pays, co-insurance, or deductibles.
Patients who have both Medicaid and Medicare (including Medicare Advantage) should never be charged for services covered under Medicaid or Medicare. Billing for covered services is illegal under both federal and state law.
Issue Brief: Dual Eligible Special Needs Plans (D-SNPs): What Advocates Need to Know, January 2022
Issue Brief: Qualified Medicare Beneficiary (QMB) Protections in Medicare Advantage: Issues, Tips, and Avenues for Advocacy, December 2019
Issue Brief: Advance Beneficiary Notices, Administrative Fees, and Dual Eligibles, February 2018
Issue Brief: Fighting Improper Billing of Dual Eligibles: New Strategies, February 2017
Issue Brief: QMB Identification Practices: A Survey of State Practices., March 2017
Fact Sheet: Summary of CMS Administrative Changes for QMB Improper Billing, September 2019
FAQ: Low Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services, August 2019
Chart: Summary of Administrative Changes for QMB Improper Billing, September 2018
Chart: State-specific Improper Billing Authorities, February 2017
Improvements to the Qualified Medicare Beneficiary Program (QMB) – Part 2 – September 25, 2018
Improvements to the Qualified Medicare Beneficiary Program (QMB) – Part 1 – September 24, 2018
California Balance Billing Protections: What Advocates Need to Know – July 25, 2018
Breakthrough Changes in Improper Billing – October 2, 2017
Protecting Dual Eligibles from Balance Billing – February 23, 2016
Protecting Dual Eligibles from Balance Billing: What Advocates Need to Know – February 23, 2016
Overview of Model Letters to Providers-National
Model Improper Billing Letter No. 1 (Client with Original Medicare and QMB+)
Model Improper Billing Letter No. 2 (Client with Original Medicare and QMB-only)
Model Improper Billing Letter No. 3 (Client with Medicare Advantage and QMB+)
Model Improper Billing Letter No. 4 (Client with Medicare Advantage and QMB-only)
Model CA Improper Billing Letter No. 1 (Client with Original Medicare and QMB+)
Model CA Improper Billing Letter No. 2 (Client with Original Medicare and QMB-only)
Medicare Learning Network Booklet: Dually Eligible Beneficiaries under Medicare and Medicaid (February 2022)
Three Tips for QMBs Dealing with Wrongful Billing (in English)
What to Do if You’re Wrongfully Billed (in Spanish)
Three Tips for QMBs Dealing with Wrongful Billing (in Spanish)
Medicare-Medicaid General Information-Billing
Blog Post: CMS Report Finds Widespread Illegal Billing of Low Income Medicare Beneficiaries
Call Letter: Prohibition on Billing Medicare-Medicaid Enrollees for Medicare Cost Sharing
Medicare Learning Network Notice: Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program
Medicare Learning Network Notice: Issuing Compliance Letters to Specific Providers and Suppliers Regarding Inappropriate Billing of Qualified Medicare Beneficiaries (QMBs) for Medicare Cost-Sharing
The resources in this section reflect the various issues dual eligibles face in accessing and being able to afford health care. From improper billing to helping older immigrants access health care, advocates will find resources to solve those and other issues.
Comments: Justice in Aging’s Response to Bipartisan Senators’ Request for Information on Better Serving Individuals with both Medicare and Medicaid, January 13, 2023
Comments: Justice in Aging’s comments on Revisions to Medicare Enrollment and Eligibility Rules, June 27, 2022
Fact Sheet: How Medicare Prescription Drug Reforms in the Inflation Reduction Act Help Low-Income Older Adults, August 17, 2022
Fact Sheet: CMS Finalizes Improvements in Medicare Managed Care for Dual Eligibles, May, 2022
Fact Sheet: Coverage Changes for Opioid Treatment Services for Dually Eligible Individuals, January, 2020
FAQ: Low-Income Subsidy (“Extra Help”) for Dual Eligibles Receiving Home and Community-Based Services, August, 2019
Fact Sheet: CMS Regulations Set Ground Rules for D-SNP, April 2019
Issue Brief:
8 Recommendations for Health Plans Serving Dually Eligible Individuals to Center Equity: An Overdue and Necessary Response to COVID-19, September 2020
Qualified Medicare Beneficiary (QMB) Protections in Medicare Advantage: Issues, Tips and Avenues for Advocacy, December 2019
Issue Brief: D-SNP Look-Alikes – A Primer, July, 2019
Issue Brief: Older Immigrants and Medicare, April 2019
As home to 1.4 million low-income older adults who are eligible for both Medicare and Medicaid (more than any other state), California has been a test case for a massive effort to coordinate their care. Throughout the roll-out of the state's Coordinated Care Initiative (CCI), beginning in 2014, Justice in Aging has trained thousands of advocates on the changes, heard from them about issues in the roll-out, and pushed the state for fixes. We also share our knowledge with advocates in other states to help them as their states roll out similar programs.
Coordinated Care Initiative Fix List – updated March 9, 2015
(was shared with the state’s Department of Health Care Services and CMS in June)
Issue Brief: Cal MediConnect: Unmet Need and Great Opportunity in California’s Dual Eligible Demonstration, February, 2019
Fact Sheet: Cal MediConnect Deeming, April, 2018
Fact Sheet: Cal MediConnect: Continuity of Care, May, 2015
Fact Sheet: Balance Billing in California, November, 2011
Issue Brief: Culturally Competent Outreach Strategies in Health Care Transitions, coauthored with Advocates for African American Elders, March, 2015
Issue Brief: Duals Demonstration: A First Glimpse at Lessons Learned, March, 2016
What’s Next for California’s Dual Eligibles? CalAim and the Coordinated Care Initiative, January 2020
CCI: An Update (December 2017)
CCI: Two Years into Implementation (February 2016)
CCI Advanced (2015)
CCI Basics (2015)
The California Coordinated Care Initiative: Advanced Training Consumer Protections and Benefit Package Summary
The California Coordinated Care Initiative: What Advocates Need to Know: Basics
How is the CCI Working? An Advocate Fact Sheet on evaluations of the CCI
Results:
Evaluation of Cal MediConnect – Focus Group Results
Evaluation of Cal MediConnect – Telephone Survey Results
Rapid Cycle Polling Project October 2015 | December 2015
An earlier RTI evaluation focusing on implementation of demonstrations in California, Illinois, Massachusetts, Ohio, Virginia, and Washington can be found here.
Under the Affordable Care Act Centers for Medicare and Medicaid Services (CMS) created a new office to focus exclusively on individuals who qualify for Medicare and Medicaid, dual eligibles. The new entity, the Medicare-Medicaid Coordination Office, began working with states across the country to better align Medicare and Medicaid benefits through state-run dual eligible demonstrations. Justice in Aging ensures dual eligibles entering these new programs are adequately informed of care changes; retain access to doctors of their choice; maintain services and care without disruptions; and get help navigating an appeals system that honors their due process rights.
Issue Brief: Unfinished Business: Designing Appeals Procedures in the Dual Eligible Demonstrations, December, 2014
Tool: Appeals Processes in the Dual Eligible Demonstration, September, 2013
Issue Brief: Building an Integrated Appeals System for Dual Eligibles, October, 2011
Issue Brief: Outreach and Enrollment Materials in States Implementing a Dual Eligible Demonstration, July 2015
Issue Brief: You've Got Mail: Designing Enrollment Notices for a Dual Eligible Demonstration Rollout, June, 2014
Appendix 1: Working Chart of Outreach Notices
Appendix 2:
Examples of 10 State Notices
with comments on strengths (in blue) and areas for improvement (in red):
Issue Brief: Continuity of Care in the Dual Eligible Demonstrations: A Tool for Advocates, May, 2013
Issue Brief: Ensuring Consumer Protection for Dual Eligibles in Integrated Models, July 2011
Issue Brief: Medicare and Medicaid Alignment: Challenges and Opportunities for Serving Dual Eligibles, August, 2011
Issue Brief: The Duals Demonstration: A First Glimpse at Lessons Learned, March, 2016
Issue Brief: Improving the Qualified Medicare Benefit Program for Dual Eligibles, November, 2011
The opportunity to live with dignity, regardless of financial circumstances—free from the worry, harm, and injustice caused by lack of health care, food, or a safe place to sleep. By using the power of law to strengthen the social safety net, and remove the barriers low-income seniors face in trying to access the services they need, we work to ensure the future we all envision for our loved ones and ourselves.
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