Dual Eligible Beneficiaries. These individuals may select a PCP and will be assigned a service coordinator to assure coordination of Medicare and Medicaid services.
Dual Eligible Beneficiaries. 7.12.1 Dual Eligible Beneficiaries enrolled in MiSalud are eligible, with the limitations provided below, for the Covered Services described in this Article, in addition to some coverage of Medicare cost-sharing.
Dual Eligible Beneficiaries. 7.12.1 Dual Eligible Beneficiaries enrolled in MI Salud are eligible, with the limitations provided below, for the Covered Services described in this Article, in addition to some coverage of Medicare cost-sharing.
7.12.1.1 Dual Eligible Beneficiaries Who Receive Medicare Part A Only
7.12.1.1.1 The Contractor shall arrange for the provision of Basic Coverage as provided in this Article 7, excluding services covered under Medicare Part A (hospitalization); except that MI Salud shall cover hospitalization services after the Medicare Part A coverage limit has been reached.
7.12.1.1.2 The Contractor shall not cover the Medicare Part A premium or deductible.
7.12.1.2 Dual Eligible Beneficiaries Who Receive Medicare Part A and Part B
7.12.1.2.1 The Contractor shall arrange for the provision of the following Basic Coverage services only: Dental Services, Pharmacy Services, and Hospitalization Services (after the Medicare Part A coverage limit has been reached).
7.12.1.2.2 The Contractor shall not pay Claims for the Medicare Part A premium or deductible.
7.12.1.2.3 The Contractor shall pay Claims for Medicare Part B deductibles and co-insurance.
7.12.1.3 Dual Eligible Beneficiaries Enrolled in a Medicare Part C Plan
7.12.1.3.1 Medicare Platino is a Medicare Part C Plan that includes a supplementary package of MI Salud benefits for Dual Eligible Beneficiaries. A Dual Eligible Beneficiary enrolled in a Platino plan is eligible for the Benefits listed in Sections 7.12.1.1 and 7.12.1.2 above.
7.12.1.3.2 An Enrollee who is independently enrolled in a private Medicare Advantage plan is also eligible for the Benefits listed in Sections 7.12.1 and 7.12.2 above.
7.12.2 Any MI Salud cost-sharing for Dual Eligible Beneficiaries shall be determined according to Section 7.11 and Attachment 8 of this Contract.
Dual Eligible Beneficiaries. There are six general categories of beneficiaries who have dual eligibility under both TRICARE and Medicare and whose claims will be processed under TDEFIC:
2.1 TRICARE beneficiaries, who are 65 or older and who are entitled to premium-free Medicare Part A and who have Medicare Part B;
2.2 TRICARE beneficiaries who are 65 or older and who are not entitled to premium-free Medicare Part A on their own record or the record of their current, former, or deceased spouse; but have Medicare Part B;
2.3 Active Duty Family Members (ADFMs) who are 65 or older and who are entitled to premium- free Medicare Part A only;
2.4 TRICARE beneficiaries who are entitled to premium-free Medicare Part A because of a disability or End Stage Renal Disease (ESRD) and who Medicare Part B;
2.5 ADFMs who have a disability or ESRD and are entitled to premium-free Medicare Part A only (While those with Medicare based on disability get a special enrollment period and therefore are not subject to the Part B premium surcharge, the special enrollment period does not apply to those with ESRD. ESRD patients who do not keep Medicare Part B when first eligible may have to pay a surcharge of 10% for each 12 month period that they could have enrolled in Part B but did not.); and
2.6 TRICARE eligible individuals who are entitled to premium-free Medicare Part A because of a disability, where Social Security Disability Insurance (SSDI) is awarded on appeal. These beneficiaries remain TRICARE eligible for the period where only Part A was effective. If a beneficiary declines Part B coverage he/she will be ineligible for TRICARE from the original effective date of Part B until Part B coverage is reinstated.
Dual Eligible Beneficiaries. Medical and/or IMC shall not pay Claims for services covered under the Medicare Program.
Dual Eligible Beneficiaries. 7.12.1 Dual Eligible Beneficiaries enrolled in the GHP are eligible, with the limitations provided below, for the Covered Services described in this Article 7, with the addition of some coverage of Medicare cost-sharing.
7.12.1.1 Dual Eligible Beneficiaries Who Receive Medicare Part A Only
7.12.1.1.1 The Contractor shall provide regular GHP coverage as provided in this Article 7, excluding services covered under Medicare Part A (hospitalization). However, the GHP shall cover hospitalization services after the Medicare Part A coverage limit has been reached.
7.12.1.1.2 The Contractor shall not cover the Medicare Part A premium or Deductible.
7.12.1.2 Dual Eligible Beneficiaries Who Receive Medicare Part A and Part B
7.12.1.2.1 The Contractor shall provide regular GHP coverage as detailed in this Article 7, excluding services covered under Medicare Part A or Part B. However, the GHP shall cover hospitalization services after the Medicare Part A coverage limit has been reached.
1.2.2 The Contractor shall not cover the Medicare Part A premium or Deductible.
