Dual eligibles include both full duals and partial duals.
“Full dual eligibility” means that someone is eligible for both Medicare and Medi-Cal. To have full dual eligibility, it means you qualify for full state Medi-Cal benefits as well as for Medicare. A person who qualifies for full dual eligibility may also qualify for a Dual Special Needs Plan (D-SNP). This is a type of Medicare Advantage plan that offers extra benefits beyond traditional Medicare and Medicaid.
Medicare pays for most of the covered care and benefits, but Medi-Cal pays some out-of-pocket costs for copays, coinsurance, deductibles and premiums. Medi-Cal also covers benefits that aren’t covered by a Dual Special Needs Plan, such as long-term care.
“Partial dual eligibility” means a person qualifies for a Medicare Savings Program (MSP) but is not enrolled in Medi-Cal. MSPs are managed by the Medicaid program in each state. While MSPs cover certain Medicare costs, like Medicare Part A and Part B premiums, people with partial dual eligibility don’t receive full Medicaid medical benefits.
Dual eligible beneficiaries (“Medi-Medis”) are individuals with both Medicare and MediCal. Medicare providers (like doctors and hospitals) cannot bill dual eligible beneficiaries for Medicare cost sharing. This is known as balance billing, or “improper billing,” and is illegal under both federal and state law. This means dual eligible beneficiaries cannot be charged for co-pays, co-insurance, or deductibles. Similarly, this protection also applies to Qualified Medicare Beneficiaries (QMBs).
Dual eligible beneficiaries or QMBs should never receive a bill for Medicare cost sharing. These beneficiaries should not pay for physician visits and other medical care when they receive Medicare-covered services. For beneficiaries in a Medicare Advantage plan, including a Medi-Medi Plan, beneficiaries should not pay for medical care when they receive covered services from a provider in their provider network. This applies to both Medicare and Medi-Cal providers. Even if a Medicare provider is not enrolled in Medi-Cal, the provider may not bill the dual eligible beneficiary. Please see additional resources below to learn more about balance billing.
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Chief Strategy Officer
Dr. Lance Anderson is the Chief Strategy Officer at PECAA, where he is engaged in all aspects of company strategy. He co-founded PECAA in 2007 and helped lead the organization as it grew from a small local Portland study group to a national alliance of independently owned eye care practices. He served as a board member of Rev-360 from 2015 – 2021 and helped oversee the management and successful sale of Revolution EHR, Visionary Partners, and eventually PECAA.
He earned his Doctor of Optometry degree from Pacific University in 1991. He started his own optometry practice in 1993 in Hillsboro, OR, and was able to grow the practice into a busy three-doctor clinic. He retired from clinical care in 2021 and then moved to New York City where he was tasked with helping to integrate PECAA with the HEA buying group. He recently moved to Nashville, TN where he will continue to be actively involved in creating the future vision for PECAA as it is integrated into the VSP family of businesses.
Chief Member Experience Officer
Dr. Justin Manning is the Chief Member Experience Officer at PECAA, where he leads the member experience team, encompassing member education, the Member Business Advisory services, Events, and the Cold Start program. He is the founder and host of the Practice Advantage podcast. Prior to joining PECAA, he founded The Keratoconus and Scleral Lens Institute at Bettner Vision in Colorado Springs, and eyeLeader, a consulting company focused on leadership development, technology in eyecare, and population health.
He has contributed to Review of Optometric Business and has lectured nationally and internationally on specialty contact lenses, design thinking, population health, and the patient experience. He earned his Doctor of Optometry degree from The Ohio State University and completed a residency in Geriatric Optometry at the VA Puget Sound Healthcare System in Tacoma, WA, a Master of Public Health degree at Salus University, and a graduate certificate in Customer Experience from the CU Boulder Leeds School of Business. He is driven to help all independent eye care professionals grow their businesses and enjoy their practices every single day.
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