Dual-eligible beneficiaries (Medicare dual eligibles or "duals") refers to those qualifying for both Medicare and Medicaid benefits. In the United States, approximately 9.2 million people are eligible for "dual" status. Dual-eligibles make up 14% of Medicaid enrollment, yet they are responsible for approximately 36% of Medicaid expenditures. Similarly, duals total 20% of Medicare enrollment, and spend 31% of Medicare dollars. Dual-eligibles are often in poorer health and require more care compared with other Medicare and Medicaid beneficiaries.

Medicare and Medicaid coverage for dual-eligibles

Medicare is the primary payer for most services, but Medicaid covers benefits not offered by Medicare. Medicare coverage for dual-eligibles includes hospitalizations, physician services, prescription drugs, skilled nursing facility care, home health visits, and hospice care. Under Medicaid, states are required to cover certain items and services for dual-eligibles, including long-term nursing facility services and home health services. Although states are required to cover certain populations and services, they have the option to expand coverage beyond these mandatory levels (i.e., offer home and community-based services), and accordingly state Medicaid programs vary in scope. Dual-eligibles may be categorized as full-benefit or partial-benefit. Those with full benefits may receive the entire range of Medicaid benefits; those with partial-benefits do not receive Medicaid-covered services, but Medicaid covers their Medicare premiums or cost-sharing, or both. Partial benefit dual-eligible beneficiaries have limited income and assets, but their income and assets are not low enough to qualify them for full Medicaid benefits in their state.

Historical challenges with the dually-eligible

Historically, one of the major challenges for the dually-eligible has been care coordination between Medicare and Medicaid. These two systems of care do not "talk to each other" systematically, so one physician that bills primarily through Medicare may not be familiar with benefits that are available through Medicaid. Additionally, since Medicaid benefits vary by state, it is difficult for care providers and consumers to understand the complexity that is inherent within the Medicaid system.

Because duals tend to be the most vulnerable, and often sickest, adults, their care has historically been expensive, totaling $319.5 billion in 2011.

In order to resolve these pain points, the ACA includes provisions that specifically address the coverage and care of duals. On a federal level, the Centers for Medicare and Medicaid Services (CMS) has established two new offices: The Federal Coordinated Health Care Office (FCHCO aka the "duals office") as well as the Center for Medicare and Medicaid Innovation (CMMI) in order to both strategize and monitor the type and quality of care afforded to duals.

A study looking at physician's views of Medicare Part D, and in particular how it pertains to dual-eligibles, found that many physicians expressed concern regarding access to prescription drugs, especially for dual-eligibles. Almost half of physicians responded that the access to prescription drugs for dual-eligibles was worse under Part D than relative to the previous Medicaid, and more than half (63%) reported higher administration burden. Many physicians stated that dual-eligibles had less access under Part D than in three Medicaid restrictive states. This suggests that the transparency of Part D formulary coverage needs to be improved to improve access to these resources for physicians.

A further study by the same group of researchers found that despite the above physicians' views on access to healthcare among dual-eligibles, there were no statistically significant changes in pharmaceutical utilization or out-of-pocket expenditures in the 18 months after Medicare Part D implementation. When comparing a group of dual-eligibles (the experimental group) with a control group of near-elderly Medicaid-covered patients, both groups showed a decline in costs rights after the implementation of Part D, which then leveled off. The expenditures for both groups tracked each other.

References

<!--* Medicare & You handbook (PDF) on Medicare.gov &mdash; see pages 49 (59 of 104) and 58 (68 of 104) for more complete information -->

  • Medicare & You handbook Order newest (printed) or download newest(PDF) version from Medicare website.
  • Dual Eligible FAQ for claims processing by pharmacist (PDF) from cms.hhs.gov