Reporting on dual eligibles — low-income older or disabled adults who qualify for both Medicare and Medicaid — can be confusing. Each agency (and state, in the case of Medicaid) has different programs, different considerations for what’s deemed “appropriate” care, how outcomes are measured, and how care is reimbursed.
There were approximately 12.5 million dual eligibles in 2020, according to KFF. That’s about 17% of traditional Medicare enrollees and 14% of Medicaid beneficiaries. However, this group comprises much higher shares of health care spending: 33% for Medicare and 32% for Medicaid. Dual eligibles are primarily people over 65, but also include those under 65 who qualify for benefits due to lifelong intellectual and/or developmental disabilities.
Many states are already struggling to meet current Medicaid demand, and as boomers age, more stress will be placed on an already fragile system. A January 2023 issue brief from KFF found that in 2020:
- Almost nine in 10 Medicare-Medicaid enrollees (87%) lived on an annual income below $20,000 compared to one in 5 Medicare beneficiaries without Medicaid coverage (20%).
- Four in 10 Medicare-Medicaid enrollees lived on incomes less than $10,000.
- Partial-benefit Medicare-Medicaid enrollees, those who meet some, but not all criteria for benefits from both programs, had somewhat higher incomes compared to full-benefit Medicare-Medicaid enrollees,
- More than one in 10 full-benefit Medicare-Medicaid enrollees (13%) lived in a long-term care nursing home or other institutional facility, compared to 1% of all Medicare beneficiaries without Medicaid coverage.
- More than half (51%) of Medicare-Medicaid enrollees were people of color compared with 20% of Medicare beneficiaries without Medicaid
- About half (49%) were White, 22% were Black, 20% were Hispanic, and 9% belonged to other racial/ethnic groups.
- In contrast, 81% of Medicare beneficiaries without Medicaid were White and 19% were from communities of color.
- Full-benefit Medicare-Medicaid enrollees were less likely to be White and more likely to be Hispanic than partial-benefit Medicare-Medicaid enrollees.
There is growing concern about the high costs of dual eligibles and the type of care they receive. These separate programs, with different payment and approval procedures, increase 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.
Good to know
- 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.
- About one-quarter (26%) of Medicare-Medicaid enrollees in 2020 had five or more chronic conditions, compared to 15% of Medicare beneficiaries without Medicaid coverage.
- Almost half (44%) of Medicare-Medicaid enrollees reported a fair or poor health status.
- More than 40% of full duals use long-term services and supports — a far greater percentage than for other Medicare or Medicaid beneficiaries, according to the Congressional Budget Office.
- Medicare-Medicaid enrollees were more likely than Medicare beneficiaries without Medicaid to report having a limitation in activities of daily living (ADL), which include eating, bathing, toileting, dressing, and functional mobility, according to KFF.
- Among Medicare-Medicaid enrollees, 48% had at least one ADL limitation, compared to 23% of all Medicare beneficiaries without Medicaid coverage.
- Among full-benefit Medicare-Medicaid enrollees, 40% reported having limitations in two or more ADLs, 13% had one limitation in an ADL and just under half (48%) had no limitations in ADLs.
- In comparison, a smaller share (23%) of partial-benefit Medicare-Medicaid enrollees reported limitations in two or more ADLs, while somewhat higher shares had one limitation in an ADL (17%) or no limitations in ADLs (60%).
CMS guidelines mandate state coverage of certain services through their Medicaid Programs, including:
- Doctor visits.
- Inpatient and outpatient hospital services.
- Mental health services.
- Prescription drugs.
- Prenatal care, maternity care, and family planning services (for example, contraceptives).
- Preventive care, like immunizations, mammograms, and colonoscopies.
States may cover added services, including:
- Dental services
- Home- and community-based services
- Physical therapy
- Prosthetic devices
- Vision and eyeglasses
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. Some states are pursuing demonstration programs or dual eligible special needs plans (D-SNPs) as well as expanding PACE programs (Program of all inclusive care for the elderly) as options to integrate care and contain costs.
Story ideas
- Is your state participating in one of the duals demonstration programs? Profile it.
- What community-based supports are in place — or needed — to address the 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?
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 (July 2023) provides the most recent demographic and other characteristic breakdowns, expenditures, and health care utilization of dual-eligible individuals
- Medicaid Health Plans of America, represents the interests of the Medicaid managed care industry.
- Association for Community Affilliated Plans is a professional organization for safety-net health plans.
