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Medicaid Arrangements for Dual-Eligible Individuals: Coordination of Medicare and Medicaid

Around 12.5 million people in the United States are enrolled in both Medicare and Medicaid. These individuals, commonly referred to as dual-eligibles, receive primary health insurance coverage through Medicare and additional assistance from their state’s Medicaid program. Dual-eligibles typically have low incomes and limited savings, but they vary in terms of age, physical health, and mental health. While some have access to the full range of Medicaid benefits, including long-term services and supports, others have limited Medicaid coverage but receive assistance with Medicare premiums and cost sharing.

Challenges arise due to separate eligibility requirements, benefits, and rules for Medicare and Medicaid, resulting in a fragmented and disjointed system of care for dual-eligibles. To address these issues, policymakers have developed various coverage arrangements aimed at improving coordination between the two programs. Managed care plans play a crucial role in coordinating Medicare and Medicaid for dual-eligibles, particularly those who utilize services covered by both programs. However, coordination needs are relatively fewer for partial-benefit dual-eligibles who receive Medicaid assistance with Medicare cost sharing.

A survey conducted by KFF, Health Management Associates, and the National Association of Medicaid Directors, along with administrative data from the Centers for Medicare and Medicaid Services (CMS) reveals that almost all states employ strategies to coordinate care for dual-eligibles, with many states adopting multiple approaches. Let’s explore some of these arrangements in 2022.

Medicaid Managed Care

In 28 states, dual-eligible individuals receive some or all of their benefits through Medicaid managed care. Under this model, enrollees access services through health plans operated by private companies or local authorities. States may include requirements for these plans to coordinate with Medicare, such as covering Medicare cost sharing or assigning a case manager to coordinate care. Enrollees in Medicaid managed care can choose either traditional Medicare or a private Medicare plan like Medicare Advantage.

Programs of All-Inclusive Care for the Elderly (PACE)

Thirty states offer Programs of All-Inclusive Care for the Elderly (PACE). PACE provides comprehensive medical and social services to individuals aged 55 and older who require nursing home level care but can safely reside in the community. While most PACE enrollees are dual-eligibles, Medicare beneficiaries who don’t qualify for Medicaid can pay a monthly premium to enroll. PACE is available in limited service areas and has demonstrated positive outcomes for participants.

Financial Alignment Initiative (FAI)

Nine states participate in the Financial Alignment Initiative, a partnership between CMS and states to test new care models for dual-eligibles. The initiative aims to improve care coordination and align the financial incentives of Medicare and Medicaid. Participating states offer joint Medicare and Medicaid benefits through a single health plan, known as Medicare-Medicaid Plans. CMS has announced plans to transition these plans into Dual-eligible Special Needs Plans (D-SNPs) by the end of 2025, based on mixed results from evaluations of the initiative.

Dual-eligible Special Needs Plans (D-SNPs)

In 46 states, dual-eligibles have access to D-SNPs, which are Medicare Advantage plans designed for individuals with Medicaid. D-SNPs focus on coordinating benefits and care covered by both programs. There are three types of D-SNPs: coordination-only, highly integrated, and fully integrated. Coordination-only D-SNPs provide Medicare-covered services and coordinate with Medicaid. Highly integrated D-SNPs must have a Medicaid plan operating in the same area, while fully integrated D-SNPs integrate Medicare and Medicaid benefits into a single plan

Check out Agility’s Medicare contracting, the Medicare commissions guide, and our Medicare certifications resources for more information.

Original article titled: Medicaid Arrangements to Coordinate Medicare and Medicaid for Dual-Eligible Individuals

Published: Apr 27, 2023 by Maria Peña , Maiss Mohamed , and Alice Burns on