The Difference Integration Makes in Care for Dual Eligibles

Nearly 1 in 5 people with Medicare are also enrolled in Medicaid. For these dually eligible beneficiaries, Medicare acts as the primary insurer, with Medicaid filling in the gaps in many ways: providing secondary insurance and supplemental benefits, reducing cost sharing, or managing care coordination between the programs.

But Medicare and Medicaid often fail to work properly together, leaving dually eligible individuals with double the delays and a frustrating lack of clarity about how to access help and care. In a new case study series, Making Medicare and Medicaid Work Better Together, we tell the stories of eight dually eligible beneficiaries who called the Medicare Rights Center’s national helpline about issues with their dual coverage.

The Structure of Dual Coverage

Most dually eligible beneficiaries are “full duals,” which means they have both Medicare and the full breadth of Medicaid coverage available in their state. Others are “partial duals,” which refers to Medicare beneficiaries enrolled in a Medicare Savings Program (MSP) that reduces cost sharing and provides some additional benefits, including assistance with drug costs and increased flexibility in Part B enrollment.

There are four types of MSPs, and each has different eligibility thresholds. MSPs are administered by state Medicaid agencies, and each state sets its own limits for eligibility. The video below details how income and resources are counted for MSP eligibility and compares the different programs’ benefits.

Other Medicaid programs and pathways also vary by state, but there are certain types of Medicaid available to Medicare beneficiaries in all states: Aged, Blind and Disabled (ABD) Medicaid; Institutional Medicaid for nursing home care; and home- and community-based services (HCBS) Medicaid waiver programs. Many states have also expanded access to Medicaid through the Affordable Care Act for adults with incomes up to 138% of the poverty level who are not yet eligible for Medicare.

Integrated and Automatic Appeals

The case study in Fixing the Appeals Process includes the story of Mrs. Z, a New Yorker enrolled in a Medicaid Advantage Plus (MAP) plan, a type of integrated managed care plan for dual eligibles in long-term care. After receiving denials from her plan for several benefits, she was unsure where to appeal. But when she spoke to a Medicare Rights counselor, she learned that her MAP plan participated in New York’s Integrated Appeals and Grievances demonstration, which automatically submitted an appeal on her behalf to the Integrated Administrative Hearings Office. This meant the state had all the information it needed about her dual coverage to confirm her eligibility for the claims, and she received quick and favorable decisions without having to appeal to both Medicare and Medicaid by herself, allowing her to connect more easily to needed care.

Proactive Care Coordination

The Improving Care Coordination brief also features an instance of effective integration by a MAP plan that protected a beneficiary’s access to care without leaving him to navigate the process alone. When Mr. Y accidentally disenrolled from a plan that covered his medically necessary 24-hour home care, the unexpected and uncharacteristic decision alerted his assigned care manager at the MAP plan. Before Mr. Y’s 24-hour care could be interrupted, his care manager contacted him, assessed his situation and care needs, and helped him re-enroll in his integrated plan.

Policy Directions

The stories from Mrs. Z and Mr. Y show that integrated care for dual Medicare and Medicaid beneficiaries can be seamless and effective. Good systems do not require beneficiaries to initiate and navigate complicated processes. Often, excessive administrative burdens—like the ones involved in dual appeals processes—worsen inequity and inaccessibility among a population already experiencing medical and economic hardship.

There are clear opportunities to modernize and improve MSPs and the beneficiary experience.

Unfortunately, Congress is moving in the opposite direction. The Republican reconciliation bill (HR 1) halted rules designed to streamline application processes, stymieing recent efforts to increase MSP access. The Congressional Budget Office projects nearly 1.4 million low-income people with Medicare—more than 10% of the dually enrolled Medicare-Medicaid population—will lose their MSP coverage due to the rollback of these simplifications.

State Opportunities

Importantly, HR 1 does not prevent states from taking action.

The Medicare Savings Programs are chronically under-enrolled, and states have levers to address this. We encourage all states to make it easier for people to learn about and sign up for MSPs through increased outreach, streamlined applications, and automatic enrollment where income data are already available.

States could boost MSP enrollment by developing systems that enable data matching across agencies administering Supplemental Nutrition Assistance Program (SNAP), Medicaid, MSP, or other programs that help people with low incomes.

Making MSP recertification and renewal more accessible and efficient by automating the process and reducing the paperwork burden could further promote consistent coverage and prevent unnecessary loss of benefits for enrollees.

We also urge interventions to increase MSP availability, including raising income eligibility thresholds and eliminating asset barriers that can make application processes overly burdensome. And some states are taking action: Medicare Rights has successfully advocated for streamlining MSP enrollment and expanding MSP eligibility in New York and other states.

Federal Opportunities

At the federal level, we urge Congress to immediately reverse the pause on the MSP streamlining rule and to instead advance policies that make it easier for low-income older adults and those with disabilities to access critical supports.

We also support federalizing the MSP. Standardizing eligibility requirements and applications for beneficiaries across the country would bring it in line with other cost-saving programs like Extra Help and make it easier for people to get the help they need.

Lawmakers must adequately fund outreach and enrollment efforts, including through the State Health Insurance Assistance Program (SHIP). SHIPs uniquely provide objective, free, one-on-one assistance to Medicare beneficiaries, their families, and caregivers, empowering them to make informed decisions about their coverage and care.

Read the new case study series, Making Medicare and Medicaid Work Better Together.