Nearly one in five Medicare enrollees is also enrolled in Medicaid. For these dual-eligible beneficiaries, Medicare serves as the primary insurance company and Medicaid fills in the gaps in many ways: providing secondary coverage and supplemental benefits, reducing cost-sharing, or managing care coordination among plans.
But Medicare and Medicaid often don't work well together, causing dually eligible individuals to suffer double the delays and a frustrating lack of clarity on how to get help and care. In a new case study series, Making Medicare and Medicaid work better togetherwe tell the stories of eight dual-eligible beneficiaries who called the Center for Medicare Rights’ national helpline with questions about their dual coverage.
Double covered structure
Most dual-eligible beneficiaries are “full dual beneficiaries,” meaning they have both Medicare and full Medicaid coverage in their state. Others are “partial dual,” referring to Medicare beneficiaries enrolled in the Medicare Savings Plan (MSP), which reduces cost-sharing and offers some additional benefits, including drug cost assistance and increased flexibility in Part B enrollment.
There are four types of MSP, each with different eligibility thresholds. MSP is administered by state Medicaid agencies, and each state sets its own eligibility limits. The video below details how to calculate income and resources for MSP eligibility and compares the benefits of different plans.
Other Medicaid programs and pathways also vary by state, but certain types of Medicaid are 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 Program. Many states have also expanded access to Medicaid through the Affordable Care Act to adults with incomes up to 138 percent of the poverty level who are not yet eligible for Medicare.
Integrated and automated appeals
case study in Fix appeals process Includes the story of Ms. Z, a New Yorker who is enrolled in the Medicaid Advantage Plus (MAP) plan, a comprehensive managed care plan for long-term care dual-eligibles. After being denied multiple benefits plans, she was unsure where to appeal. But when she spoke with a Medicare Rights Counselor, she learned that her MAP plan participated in New York's Comprehensive Appeals and Grievance Demonstration, which automatically filed an appeal on her behalf with the Office of Comprehensive Administrative Hearings. This meant the state had all the information it needed about her dual coverage to confirm her claim eligibility, and she got a quick and favorable decision without having to appeal to Medicare and Medicaid herself, making it easier for her to get the care she needed.
Proactive care coordination
this Improve care coordination The briefing also presented examples of effective integration of MAP programs that protect the beneficiary's access to care without having to navigate the entire process alone. When Mr. Y unexpectedly dropped out of the plan that covered his medically necessary 24-hour home care, this unexpected and unusual decision alerted his designated MAP plan care manager. Before Mr. Y's 24-hour care was interrupted, his care manager contacted him, assessed his situation and care needs, and helped him rejoin the comprehensive plan.
policy direction
The stories of Ms. Z and Mr. Y illustrate that integrated care for dual Medicare and Medicaid beneficiaries can be seamless and effective. Good systems do not require beneficiaries to initiate and navigate complex processes. Often, excessive administrative burdens, such as those involving dual appeals processes, can exacerbate inequalities and inaccessibility for populations already experiencing medical and economic hardship.
Excessive administrative burdens exacerbate inequalities and inaccessibility for populations already experiencing medical and economic hardship.
There is a clear opportunity to modernize and improve MSPs and the beneficiary experience.
Unfortunately, Congress is moving in the opposite direction. The Republican Reconciliation Act (H.R. 1) stymied recent efforts to increase MSP access by halting rules designed to streamline the application process. The Congressional Budget Office estimates that nearly 1.4 million low-income people on Medicare (more than 10% of the dually enrolled Medicare-Medicaid population) will lose MSP coverage as a result of the elimination of these simplifications.
national opportunity
Importantly, HR 1 does not prevent states from taking action.
Medicare Savings Plans are chronically underinsured, and states have ways to address the problem. We encourage all states to make it easier for people to learn about and sign up for MSP by expanding outreach, streamlining applications, and automating enrollment when income data is already available.
States can improve MSP enrollment by developing systems that enable data matching between agencies that administer the Supplemental Nutrition Assistance Program (SNAP), Medicaid, MSP or other programs that help low-income people.
States can improve MSP enrollment by developing systems that support cross-institutional data matching.
Making MSP recertification and renewal easier and more efficient by automating the process and reducing paperwork burden can further promote coverage consistency and prevent unnecessary loss of benefits for enrollees.
We also urge interventions to increase the availability of MSP, including raising income eligibility thresholds and removing asset barriers that may make the application process overly cumbersome. Some states are taking action: Medicare Rights has successfully advocated to streamline MSP enrollment and expand MSP eligibility in New York and other states.
federal opportunities
At the federal level, we urge Congress to immediately reverse the suspension of MSP streamlined rules and instead advance policies that make it easier for low-income seniors and people with disabilities to access critical supports.
We also support federalizing MSP. Standardizing beneficiary eligibility requirements and applications nationwide 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.
Standardizing eligibility requirements and applications nationwide will align MSP with other cost-saving programs.
Lawmakers must provide adequate funding for outreach and enrollment efforts, including through the State Health Insurance Assistance Program (SHIP). SHIP uniquely provides Medicare beneficiaries, their families and caregivers with objective, free, one-on-one assistance so they can make informed decisions about their coverage and care.
Read the new case study series, Making Medicare and Medicaid work better together.
