Certified Community Behavioral Health Clinics Demonstration Program: Report to Congress, 2018. Paying for Services Provided to Dually Eligible Beneficiaries


Certain Medicare beneficiaries are eligible for some level of Medicaid assistance. These individuals are often referred to as "dually eligible" beneficiaries. Section 223 requires states to pay up to the PPS rate for demonstration services provided to dually eligible beneficiaries for whom the state must share in the cost of direct services, rather than just Medicare cost sharing for all demonstration services delivered to Medicaid beneficiaries. Specifically, CMS guidance[7] states the following:

  • There are two types of dually eligible beneficiaries--Qualifying Individuals (QI), and Qualified Disabled and Working Individuals (QDWI)--for whom Medicaid pays some or all of their Medicare premiums, but does not pay for services. Under a demonstration, no Medicaid payment would be made for services furnished to such individuals by certified clinics.

  • For Qualified Medicare Beneficiaries (QMBs), states must pay Medicare cost sharing, but may adopt a methodology paying the lesser of Medicare cost sharing or the amount that would result in total payment equal to the PPS.

  • Specified Low-Income Medicare Beneficiaries (SLMB) are generally eligible only for payment of Medicare premiums, but there is a state option to pay Medicare Part B cost sharing. To the extent the state elects this option, demonstration services for SLMBs would be treated the same way as services for QMBs otherwise, no Medicaid payment would be due for demonstration services. For full-benefit dual-eligible individuals, the statute requires payment up to PPS (after accounting for the Medicare payment).

  • Thus, PPS is not required to be paid for services provided to the following dually eligible beneficiaries: QI, QDWI and SLMB only.