4.2 Dual Eligibility & Medicare Savings Programs

AHIP Medicare Certification Exam

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1 Introduction

1.1 About the AHIP Medicare Certification Exam 1.2 How to Use This Study Guide

2 Chapter 2: Medicare Program Fundamentals

2.1 What Medicare Is: Program Structure & How Parts A–D Fit Together 2.2 Medicare Part A — Hospital Insurance 2.3 Medicare Part B — Medical Insurance 2.4 Medicare Eligibility Rules (Age 65, Disability, ESRD, ALS)

3 Chapter 3: Medicare Enrollment Periods

3.1 Initial Enrollment Period (IEP) 3.2 Annual Enrollment Period (AEP): October 15 – December 7 3.3 Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31 3.4 Special Enrollment Periods (SEPs) & Qualifying Life Events 3.5 Late Enrollment Penalties (Part A, Part B, Part D)

4 Chapter 4: Medigap & Coordination of Coverage

4.1 Medigap (Medicare Supplement) Basics & Guaranteed Issue Rights 4.2 Dual Eligibility & Medicare Savings Programs 4.3 How Original Medicare, MA, Part D & Medigap Interact

5 Chapter 5: Medicare Advantage Plan Types

5.1 Medicare Advantage (Part C) Overview: How MA Differs from Original Medicare 5.2 HMO & HMO-POS Plans 5.3 PPO Plans 5.4 PFFS Plans (Private Fee-for-Service) 5.5 MSA Plans (Medicare Medical Savings Accounts) 5.6 Cost Plans & Employer Group Waiver Plans (EGWPs)

6 Chapter 6: Special Needs Plans & MA Plan Design

6.1 Special Needs Plans (SNPs) Overview 6.2 D-SNP — Dual-Eligible Special Needs Plans 6.3 C-SNP & I-SNP — Chronic Condition & Institutional Special Needs Plans 6.4 MA Benefits, MOOP & Supplemental Benefits 6.5 MA Star Ratings & Plan Quality

7 Chapter 7: Part D Structure & the 2026 Redesign

7.1 Part D Overview & Eligibility 7.2 Formularies & Drug Tiers 7.3 The 2026 Part D Benefit Redesign ($2,100 OOP Cap, $615 Max Deductible, Catastrophic Phase) 7.4 Medicare Prescription Payment Plan (Drug-Cost Smoothing)

8 Chapter 8: Part D Costs, Assistance & Appeals

8.1 Low-Income Subsidy (LIS) / Extra Help 8.2 Part D Late Enrollment Penalty & Creditable Coverage 8.3 Coverage Determinations, Exceptions & Appeals

9 Chapter 9: CMS Marketing Rules & Scope of Appointment

9.1 CMS Medicare Communications & Marketing Guidelines (MCMG) Overview 9.2 Scope of Appointment (SOA): the 48-Hour Rule & Exceptions 9.3 Permitted vs. Prohibited Marketing & Sales Activities 9.4 Marketing Events vs. Educational Events

10 Chapter 10: Enrollment & Disclosure Requirements

10.1 The Pre-Enrollment Checklist (PEC) 10.2 Enrollment Procedures & Application Requirements 10.3 Call Recording & Third-Party Marketing Organization (TPMO) Disclaimers 10.4 Agent & Broker Compensation Rules

11 Chapter 11: Marketing Conduct & Oversight

11.1 Cross-Selling Restrictions & Nominal Gift Value Rules 11.2 Marketing to Vulnerable Populations & Non-Discrimination in Sales 11.3 Website, Social Media & Advertising Compliance 11.4 Complaint Tracking Module (CTM) & Agent Oversight

12 Chapter 12: Understanding Fraud, Waste & Abuse

12.1 Defining Fraud, Waste & Abuse (and the Difference Between Them) 12.2 The False Claims Act 12.3 The Anti-Kickback Statute

13 Chapter 13: Compliance Laws & Screening

13.1 The Stark Law (Physician Self-Referral) 13.2 HIPAA Privacy & Security Basics 13.3 The OIG Exclusion List & Sanctioned-Provider Screening

14 Chapter 14: Reporting, Compliance Programs & Consequences

14.1 Detecting & Reporting FWA 14.2 Compliance Program Requirements (Seven Core Elements) & Non-Discrimination Training 14.3 Consequences & Corrective Action Plans

4.2 Dual Eligibility & Medicare Savings Programs

Key Takeaways Explain This Topic AI

"Dual eligible" means enrolled in both Medicare and Medicaid; "full duals" get comprehensive Medicaid benefits, while "partial duals" only get help with Medicare premiums and cost-sharing through a Medicare Savings Program (MSP).

The four MSP categories — QMB, SLMB, QI, and QDWI — are ranked by income as a percentage of the Federal Poverty Level (FPL); QMB and QDWI cover premiums plus different scopes of cost-sharing, while SLMB and QI cover the Part B premium only.

QMB (Qualified Medicare Beneficiary) is the only MSP that pays Part A/B deductibles, coinsurance, and copays in addition to premiums — and federal law bans providers from balance-billing QMB enrollees even when Medicaid's payment is less than the full Medicare cost-share.

Dual-eligible status (especially QMB and full-dual status) is what qualifies a beneficiary to enroll in a D-SNP, so getting the MSP category right connects directly to the SNP content in Chapter 6.

Beneficiaries who qualify for QMB, SLMB, or QI are automatically "deemed" eligible for full Part D Extra Help without a separate Social Security application.

Last updated: July 2026

Why This Topic Matters

Agents who work with low-income Medicare beneficiaries will run into dual eligibility constantly, and AHIP tests it both directly (identifying which MSP a beneficiary qualifies for) and indirectly (as the gateway to D-SNP enrollment, covered in Chapter 6). A wrong answer here has real consequences outside the exam room too: telling a QMB beneficiary they owe a copay a provider is billing them for is not just an exam trap, it is agent malpractice, because federal law makes that bill illegal.

Defining Dual Eligibility

A dual-eligible beneficiary is enrolled in both Medicare and Medicaid. CMS splits dual eligibles into two groups:

Full-benefit dual eligibles ("full duals"): Qualify for the complete Medicaid benefit package in their state — this can include long-term care, personal care services, dental, vision, and other benefits Medicare does not cover at all, in addition to help with Medicare cost-sharing.

Partial-benefit dual eligibles ("partial duals"): Qualify for Medicaid assistance only through one of the four Medicare Savings Programs (MSPs) below. They do not receive full Medicaid medical benefits — Medicaid's role is limited to helping with specific Medicare costs.

The Four Medicare Savings Programs

MSPs are administered by state Medicaid agencies (so exact dollar thresholds vary slightly by state) using a base federal income test expressed as a percentage of the Federal Poverty Level (FPL) . The four tiers, from most to least restrictive, are:

Program Approx. 2026 income limit (individual) What it pays

QMB (Qualified Medicare Beneficiary) About 100% FPL (~$1,350/month) Part A premium (if any), Part B premium, plus Part A/B deductibles, coinsurance, and copays

• SLMB (Specified Low-Income Medicare Beneficiary) About 100–120% FPL (~$1,616/month) Part B premium only
• QI (Qualifying Individual) About 120–135% FPL (~$1,816/month) Part B premium only

QDWI (Qualified Disabled and Working Individual) About 200% FPL, for under-65 disabled workers Part A premium only

Asset limits apply too — roughly $9,950 for an individual and $14,910 for a couple in most states in 2026 (some states waive the asset test entirely or use higher limits). QDWI is a narrow category: it is only for people under 65 who have a disability, lost premium-free Part A because they returned to work and earn too much to qualify for it for free, and need help paying the resulting Part A premium .

The QMB Balance-Billing Rule

The single most important compliance fact in this section: it is illegal for any Medicare provider — regardless of whether they are in-network or out-of-network, or whether Medicaid pays them the full coinsurance amount — to bill a QMB beneficiary for Medicare Part A or Part B deductibles, coinsurance, or copayments. This rule exists under federal Medicaid law (traced back to the Balanced Budget Act) and applies nationwide, even in states where the state Medicaid program reimburses providers less than the full Medicare cost-sharing amount. Providers who violate it can face sanctions.

Common exam trap: A question may describe a QMB beneficiary who receives a bill from a provider for a coinsurance amount and ask what the agent should tell them. The correct answer is always some version of "this bill is not valid — QMB status protects you from being billed for Medicare cost-sharing; contact the provider or your State Health Insurance Assistance Program (SHIP)." An answer suggesting the beneficiary must pay it, or that this only applies to in-network providers, is wrong.

MSPs and D-SNP Eligibility

Dual-eligible status (both full and partial, depending on the specific D-SNP's state contract) is the gateway credential for enrolling in a Dual-Eligible Special Needs Plan (D-SNP) , discussed in depth in Chapter 6. An agent evaluating whether a client might benefit from a D-SNP should first confirm the client's MSP category or full-dual status, since D-SNP eligibility rules are built directly on top of these categories.

The MSP-to-Extra-Help Connection

One fact agents frequently miss: anyone who qualifies for QMB, SLMB, or QI (the partial-dual MSPs) — along with full-benefit dual eligibles and SSI recipients on Medicare — is automatically deemed eligible for full Part D Low-Income Subsidy (Extra Help) , without needing to file a separate application with the Social Security Administration. This "deeming" happens because the state Medicaid agency shares eligibility data with CMS. The practical impact for the beneficiary is significant: full Extra Help eliminates the Part D deductible, caps generic copays at just a few dollars, and removes the coverage-gap cost-sharing bump entirely (Chapter 8 covers Extra Help's exact copay tiers in detail). An agent who identifies that a client qualifies for QMB, SLMB, or QI should always flag that the client likely already has, or should confirm, Extra Help — leaving this unconfirmed can mean a beneficiary pays full Part D cost-sharing they never actually owed.

Scenario

Ms. Alvarez has a monthly income of $1,320 and minimal assets. Because her income falls under the roughly 100% FPL threshold, she qualifies for QMB — Medicaid pays her Part A premium (if she owes one), her Part B premium, and all her Medicare deductibles, coinsurance, and copays. When a physical therapy clinic later sends her a bill for a $40 coinsurance charge, that bill is improper: federal law prohibits providers from balance-billing a QMB beneficiary for Medicare cost-sharing.

By contrast, Mr. Diallo has a monthly income of $1,700 — too high for QMB but within the SLMB range. Medicaid pays only his Part B premium; he remains responsible for Part A/B deductibles and coinsurance the way any Original Medicare beneficiary would be, unless he separately qualifies for full Medicaid benefits.