Chapter 3 Tables

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Strategies to Improve Access to Behavioral Health Care Services through Medicare and Medicaid; Udara Perera; Abigail Godwin; Daniel Polsky

Appendix CChapter 3 Tables

Publication Details

TABLE C-1

Medicaid Eligibility and Benefits by Type of Dual-Eligible Beneficiary.

TABLE C-2

Range of Behavioral Health and Wellness Services Covered by Medicare.

REFERENCES

CMS (Centers for Medicare and Medicaid Services). Medicare & mental health coverage. Baltimore, MD: Centers for Medicare and Medicaid Services Medicare Learning Network; 2023. [June 13, 2024]. https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf .
MedPAC. Data book: Beneficiaries dually eligible for Medicare and Medicaid. Washington, DC: Medicare Payment Advisory Commission and the Medicaid and CHIP Payment and Access Commission; 2022. [June 13, 2024]. https://www.macpac.gov/publication/data-book-beneficiaries-duallyeligible-for-medicare-and-medicaid-3/

Publication Details

Copyright

Publisher

National Academies Press (US), Washington (DC)

NLM Citation

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Strategies to Improve Access to Behavioral Health Care Services through Medicare and Medicaid; Perera U, Godwin A, Polsky D, editors. Expanding Behavioral Health Care Workforce Participation in Medicare, Medicaid, and Marketplace Plans. Washington (DC): National Academies Press (US); 2024 Oct 7. Appendix C, Chapter 3 Tables.

TABLE C-1Medicaid Eligibility and Benefits by Type of Dual-Eligible Beneficiary

Type	Full or partial Medicaid benefits	Federal income and asset (individual/couple) limits for eligibility in 2021	Benefits
Medicare Savings Program (MSP) beneficiaries
Qualified Medicare beneficiary (QMB)	Partial: QMB only	At or below l00% FPL 7,970 / $11,960	Entitled to Medicare Part A, eligible for Medicaid only under MSP, and qualify for Medicaid payment of: Medicare Part A premiums (if needed) Medicare Part B premiums At state option, certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D, the Medicare drug program)
Qualified Medicare beneficiary (QMB)	Full: QMB plus	At or below 100% FPL 2,000 / $3,000	Entitled to Medicare Part A, eligible for Medicaid under a mandatory or optional pathway in addition to MSP, and qualify for Medicaid payment of: Medicare Part A premiums (if needed) Medicare Part B premiums At state option, certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D) All Medicaid-covered services
Specified low-income Medicare beneficiary (SLMB)	Partial: SLMB only	101%–120% FPL 7,970 / $11,960	Entitled to Medicare Part A, eligible for Medicaid only under MSP, and qualify for Medicaid payment of: Medicare Part B premiums
Specified low-income Medicare beneficiary (SLMB)	Full: SLMB plus	101%–120% FPL 2,000 / $3,000	Entitled to Medicare Part A, eligible for Medicaid under a mandatory or optional pathway in addition to MSP, and qualify for Medicaid payment of: Medicare Part B premiums At state option, certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except nominal copayments in Part D); state may elect to pay only for Medicare services covered by Medicaid All Medicaid-covered services
Qualifying individual (QI)	Partial	121%–135% FPL 7,970 / $11,960	Entitled to Medicare Part A, eligible for Medicaid only under MSP, and qualify for Medicaid payment of: Medicare Part B premiums
Qualified disabled and working individuals (QDWI)	Partial	At or below 200% FPL 4,000 / $6,000²	Lost Medicare Part A benefits because of their return to work but eligible to purchase Medicare Part A, eligible for Medicaid only under MSP, and qualify for Medicaid payment of: Medicare Part A premiums
Non-MSP beneficiaries
Other full-benefit dual-eligible beneficiaries	Full	Income limit varies, but generally at or below 300% of the federal Supplemental Security Income benefit rate (about 225% FPL for an individual) 2,000 / $3,000	Eligible under a mandatory or optional Medicaid pathway, not eligible for MSP, and qualify for Medicaid payment of: At state option. certain premiums charged by Medicare Advantage plans Medicare deductibles, coinsurance, and copayments (except for nominal copayments in Part D); state may elect to pay only for Medicare services covered by Medicaid All Medicaid-covered services

: SOURCE: MedPAC, 2022.

TABLE C-2Range of Behavioral Health and Wellness Services Covered by Medicare

The range of behavioral health and wellness services covered by Medicare varies depending on the care setting and profession but includes:
Alcohol misuse screening and up to four brief, face-to-face counseling sessions per year for adults who use alcohol but are not dependent
Annual wellness visits to develop or update a personalized prevention plan, including health risk assessment and depression screening
Behavioral health integration by clinical staff to assess, monitor, and plan care
Bundled opioid use disorder payments for management and counseling and in-office services such as overall case management, care coordination, individual and group psychotherapy, and substance use counseling
Caregiver-focused behavioral health risk assessment of their own behavior and health risks, which benefits the patient
Cognitive assessment and care planning
Depression screening up to 15 minutes annually when staff-assisted depression care supports can assure accurate diagnosis, effective treatment, and follow-up
Diagnostic psychological and neuropsychological tests
Electroconvulsive therapy
Family psychotherapy
Health and behavioral assessment and intervention identifying or treating psychological, behavioral, emotional, cognitive, and social factors important to prevent, treat, or manage physical health issues
Individual and group psychotherapy Hypnotherapy Medication-assisted treatment for SUDs Psychoanalysis
Psychiatric evaluation that systematically evaluates a psychiatric disorder’s causes, symptoms, and course and consequences

: SOURCE: CMS, 2023.