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Examining Medicare and Medicaid coordination for dual-eligibles : hearing before the Special Committee on Aging, United States Senate, One Hundred Twelfth Congress, second session, Washington, DC, July 18, 2012.
Nationwide, 9 million individuals are dually eligible for both Medicaid and Medicare services. These "dual eligibles" are low-income seniors and individuals with disabilities who rely on Medicare for coverage of acute care medical services (such as hospital, physician, prescription drugs, and post-acute care) and on Medicaid for financial assistance with Medicare's premiums and cost sharing. Most dual eligibles also rely on Medicaid to provide coverage for services not included in Medicare, particularly long-term care. Dual eligibles have long been of interest to policymakers due to their relatively high health care needs and correspondingly high cost: Although dual eligibles represent only 21 percent of the Medicare population and 15 percent of the Medicaid population, they account for nearly 36 percent of total Medicare spending and 39 percent of total Medicaid spending. Policymakers are exploring strategies to better coordinate and integrate care for dual eligibles and align financing for this population. Finding realistic, effective strategies is challenging for many reasons. Medicare and Medicaid are two different, very large public health insurance programs that operate separately and sometimes work at cross-purposes. Medicare is a federal program while Medicaid is a joint federal-state program that differs across states. Further, there is great diversity among dual eligibles in their health care needs. Some dual eligibles have relatively limited needs whereas others are among the nation's most vulnerable individuals with complex health conditions and high medical and long-term care costs. Despite their considerable policy importance, limited work has been done that examines combined Medicaid and Medicare service use and spending patterns for dual eligibles. In this brief, we update a previous study and present findings based on analysis of linked 2007 Medicare and Medicaid data. Specifically, we examine characteristics, health status, utilization, and spending for dual eligibles compared to the non-dual Medicare population.
In 2009, the federal and state governments spent a total of more than $250 billion on health care benefits for the 9 million low-income elderly or disabled people who are jointly enrolled in Medicare and Medicaid. Those eligible to receive benefits from both programs at the same time are “dual-eligible beneficiaries.†All of those beneficiaries qualify for full Medicare benefits, but they differ in the amount of Medicaid benefits for which they are eligible. Seven million are “full duals,†who qualify for full benefits from both programs. The other 2 million are “partial duals,†who do not meet the eligibility requirements for full Medicaid benefits but qualify to have Medicaid pay some of the costs they incur under Medicare. This report examines the characteristics and costs of dual-eligible beneficiaries, focusing on 2009. It also examines the different payment systems that Medicare and Medicaid use to fund care for dual-eligible beneficiaries and recent efforts at the federal and state levels to integrate those payment systems and to coordinate the care that such beneficiaries receive from the two programs. Figures and tables. This is a print on demand report.
The Medicare and Medicaid programs spent an estimated $300 billion on dual-eligible beneficiaries-those individuals who qualify for both programs-in 2010. These beneficiaries often have complex health needs, increasing the need for care coordination across the two programs. In 2013, CMS began the Financial Alignment Demonstration, with the goal of integrating Medicare and Medicaid services and financing and improving care coordination. Thirteen states are participating. GAO was asked to examine care coordination under the demonstration. GAO examined (1) how integrated care organizations-which are health plans or other entities-are implementing care coordination and (2) what, if any, challenges organizations have encountered in implementing care coordination and the extent to which CMS oversees these care coordination activities. GAO interviewed officials from CMS and, during site visits to a nongeneralizable sample of the first five states to implement the demonstration, interviewed state officials, organizations, advocacy groups, and providers. GAO also reviewed CMS guidance outlining CMS's oversight role and the measures it uses to monitor the demonstration.
The Medicare and Medicaid programs spent an estimated $300 billion on dual-eligible beneficiaries -- those individuals who qualify for both programs -- in 2010. These beneficiaries often have complex health needs, increasing the need for care coordination across the two programs. In 2013, the Centers for Medicare & Medicaid Services (CMS) began the Financial Alignment Demonstration, with the goal of integrating Medicare and Medicaid services and financing and improving care coordination. Thirteen states are participating. This report examined (1) how integrated care organizations -- health plans or other entities -- are implementing care coordination; and (2) what, if any, challenges organizations have encountered in implementing care coordination and the extent to which CMS oversees these care coordination activities. Tables and figures. This is a print on demand report.
"About 9 million of Medicare's over 48 million beneficiaries are also eligible for Medicaid because they meet income and other criteria. These dual-eligible beneficiaries have greater health care challenges than other Medicare beneficiaries, increasing their need for care coordination across the two programs. In addition to meeting all the requirements of other MA plans, D-SNPs are required by CMS to provide specialized services targeted to the needs of dual-eligible beneficiaries as well as integrate benefits or coordinate care with Medicaid services. GAO was asked to examine D-SNPs' specialized services to dual-eligible beneficiaries. GAO (1) analyzed the characteristics of dual-eligible beneficiaries in D-SNPs and other MA plans, (2) reviewed differences in specialized services between D-SNPs and other MA plans, and (3) reviewed how D-SNPs work with state Medicaid agencies to enhance benefit integration and care coordination. GAO analyzed CMS enrollment, plan benefit package, projected revenue, and beneficiary health status data; reviewed 15 D-SNP models of care and 2012 contracts with states; and interviewed representatives from 15 D-SNPs and Medicaid agency officials in 5 states."
Medicare is a federal program that provides health insurance coverage to people who have disabilities, are diagnosed with certain medical conditions, or are age 65 or older. Medicaid, which is funded jointly by the federal government and the states, provides health care coverage to low-income people who meet specific requirements for income and assets and other eligibility criteria. People who are eligible to receive benefits from both programs at the same time are known as dual-eligible beneficiaries'. This book examines the characteristics and costs of dual-eligible beneficiaries, focusing on 2009, the most recent year for which comprehensive data were available when the Congressional Budget Office (CBO) began this analysis.
This research, based on a survey of 50 states and the District of Columbia conducted in the fall of 2012, finds that two-thirds of the states either have or will launch new initiatives to better coordinate care for people who are dually eligible for Medicare and Medicaid services, the so-called "duals," over the next 2 years. To contain the growth of costs and improve care, the federal government, in partnership with many states, is exploring models to better serve duals and align the Medicaid and Medicare programs to remove adverse incentives and improve care coordination. This research also finds that some states are taking the opportunity extended by the Centers for Medicare & Medicaid Services (CMS) to test new models, but a number of states are exploring or implementing alternative approaches to dual services integration outside of the CMS models.