By Liz Seegert

Dual eligibles are low-income elderly or disabled people jointly enrolled in both Medicare and Medicaid. The distinctions are sometimes bewildering. It’s easy to confuse which program pays for what, what each agency considers “appropriate” care, what factors go into measuring outcomes and how the separate structures of Medicare and Medicaid affect costs and quality.

According to the Congressional Budget Office, in 2009, the federal and state governments spent more than $250 billion, combined, on health care benefits for the 9 million dual eligibles. Seven million were “full duals,” who qualified for full benefits from both programs. The other two million were “partial duals,” who did not meet the eligibility requirements for full Medicaid benefits but received some benefits through the Medicaid program.

There is growing concern about the high costs of dual eligibles and the type of care they receive. The CBO points out that these separate programs, with different payment and approval procedures increases the likelihood that full duals – especially those who have many chronic conditions and functional limitations – will be treated by a variety of health care providers who are not coordinating their care, potentially increasing costs and worsening outcomes.

Many states are already struggling to meet current Medicaid demand, and as boomers age, more stress will be placed on an already fragile system.

Some key facts:

• Medicare generally pays for acute care (hospitalization and other short-term care) and post-acute care (services provided in skilled nursing facilities or elsewhere to help people recover from an acute illness or surgery).

• Medicaid pays for long-term services and supports (LTSS)—which includes long-term care as well as social support services designed to help people stay in their homes rather than move to institutions—and other benefits that Medicare does not cover, such as dental and vision services.

• Half of the full duals initially qualified for Medicare because of disability rather than age, and nearly one-fifth have three or more chronic conditions

• More than 40 percent of full duals use long-term services and supports—a far greater percentage than for other Medicare or Medicaid beneficiaries.

• Full duals make up 13 percent of the combined population of Medicare enrollees and aged, blind, or disabled Medicaid enrollees (those who might also qualify for Medicare), account for 34 percent of the two programs’ total spending on those enrollees.

CMS and the states face several key challenges in their efforts to control costs and improve care coordination. This CMS fact sheet breaks down eligibility criteria and benefits. Additionally,

• participation in Medicare’s managed care program is optional for dual-eligible beneficiaries,

• states generally have little information about, and limited control over, the provision of services covered by Medicare.

• Medicare and Medicaid contract separately with managed care organizations even if a beneficiary receives services from both programs through the same managed care organization.

• The Affordable Care Act created new options for addressing financing and quality-of-care issues for dual-eligible beneficiaries.

  • The largest initiative in that area under the new law is a three-year demonstration project to integrate Medicare’s and Medicaid’s financing for full duals, which 26 states applied to participate in.

  • However, several states have dropped out or delayed the start of their programs because of overly-ambitious timelines, according to this article.

• The Center on Budget and Policy Priorities is critical of a proposed mandated move into managed care plans for dual eligibles, saying it has the potential to cause “significant harm” to poor seniors and those with disabilities.

Additional background information

• The Kaiser Commission on Medicaid and the Uninsured brief, Financial and Administrative Alignment Demonstrations for Dual Eligible Beneficiaries Compared: States with Memoranda of Understanding Approved by CMS, compares the dual eligible integrated care demonstrations.

• Some states are pursuing dual eligible special needs plans (D-SNPs) as an option to integrate care – The National Association of State Medicaid Directors developed this working paper on advancing Medicare and Medicaid integration.

• A report by independent banking firm Triple Tree looks at some of the financial incentives among private insurers to participate and coordinate care.

• The Federal Coordinated Health Care Office (Medicare-Medicaid Coordination Office) serves people who are enrolled in both Medicare and Medicaid and works with the Medicaid and Medicare programs, across Federal agencies, States and stakeholders to align and coordinate benefits between the two programs effectively and efficiently. Their reports to Congress are available here.

  • Key players: Melanie Bella Director; Email: Melanie.Bella@cms.hhs.gov Phone: 202-260-1291 DC; Cheryl Powell Deputy Director Email: Cheryl.Powell@cms.hhs.gov Phone: 410-786-9239 Baltimore

Story ideas

• Is your state participating in one of the demonstration programs? Profile it.

• What community-based supports are in place – or needed – to address need of current and projected duals?

• Follow the money trail. Are people receiving duplicate services or tests under the separate programs? What’s being done to better coordinate care? How much is (potentially) wasted or double billed?

• What about quality? Are duals receiving care equal to Medicare-only or Medicare Advantage patients? Look at discharges, readmissions, safety-net vs. private institutions. Check out the Medicare payments by state database and hospital compare database to get started.

  • Also look at nursing home care – quality, location, facility. Is care for duals on par with other patients?

Additional resources

• The State Data Resource Center has information for state Medicaid agencies coordinating care of dual eligibles. Some frequently requested data packages for Medicare Parts A, B and D are available for download. However, states must go through a formal request process to obtain other databases.

• The MedPac Databook (Dec 2013) provides the most recent demographic and other characteristic breakdowns, expenditures, and health care utilization of dual-eligible individuals

• Medicaid Health Plans of America, industry trade association. Media Contact: Joe Reblando at 202-857-5722 or jreblando@mhpa.org.

• Association for Community Affiliated Plans– organization for safety-net health plans

• This article from the Piper Report – a leading industry consultant’s blog on Medicare, Medicaid and Health Policy.

• This Pew Charitable Trust brief on state efforts to coordinate the programs.