In our everchanging medicare market, we have an emerging demographic that is significantly underrepresented dual eligibles. For people who are eligible for both medicare and medicaid benefits, known as dual eligibles, medicare and medicaid coverage are largely complementary. Total dually eligible beneficiary population continues to grow. About 9 million people in the united states are covered by both medicare and medicaid, including lowincome seniors and younger people with disabilities.
Why arent duals counted in attribution for project incentive allocation, and pay for. Illinois department of healthcare and family services managed. Models that improve health and quality of life for people eligible for both medicaid and medicare dual eligibles are also of great importance to the adadrd population, as approximately 19% of the dual eligible population has some form of dementia. Additional billing requirements for dually eligible beneficiaries. In some instances, the target population is restricted to exclude. Transition of dual and nondual eligible lthhcp participants. Dual eligible population analysis for scan health plan national. Jan 31, 2017 health plan php programthe program for nondual eligible beneficiaries before launching the capitated program for dualeligible beneficiaries. Population characteristics that may be relevant to the passive enrollment issue include the following. In addition, dual eligibles may choose a type of ma plan called a dual eligible special needs plan dsnp, which is designed to target the needs of this population. In 2012, 43 percent of dual eligible beneficiaries were under age 65 and disabled compared with percent of the non dual eligible population. Statistics and quality cbhsq, samhsa, and by rti international in research. In medicare, they comprise 16 percent of the population but account for 27 percent of all expenditures. Dually eligible beneficiaries dually eligible beneficiaries generally describes beneficiaries enrolled in medicare and medicaid.
In the case of full duals, for example, half initially qualified for medicare because of disability rather than age, and nearly onefifth have three. Harp enrollment of eligible individuals began in new york city in october 2015, and an estimated 45,000 individuals will be enrolled in nyc harps as of 2016. Dual eligible project mmp the goal of the project is to better coordinate the care those dual eligible members receive. Dual eligibles are individuals who are entitled to medicare part a andor part b and are eligible for some form of medicaid benefit. Cmss financial alignment demonstration and the medicare savings programs have income that exceeds the ssi eligibility limit but is below the federal poverty level. Overall, the nations dual eligible population increased 20% from 20052010, spurred by a doubling of the partial dual subgroup. Report to the joint legislative oversight committee on. If camffs dual eligibles had the same readmission and hospitalization rate. Dually eligible beneficiaries under medicare and medicaid. The term includes beneficiaries enrolled in medicare part a andor part b and getting full medicaid benefits andor assistance with medicare premiums or cost sharing through the medicare savings program msp. Medicaid program medicaid is a health insurance program funded by federal and state governments that pays costs for. Dually eligible beneficiaries nder medicare and medicaid mln ooklet. To qualify for medicare, individuals generally need to be 65 or older, have a qualifying disability, or be diagnosed with endstage renal disease.
Dual eligibles and the value of medicare advantage ahip. Dual eligible population duals in medicaid transformation. Care management practices in integrated care models for dual. C behavioral health statistics and quality the cbhsq report. People dually eligible for medicare and medicaid fact. While minimum federal income and asset limits are specified, as is true for other medicaid categories of eligibility, states are permitted to make the eligibility criteria more generous. The dualeligible population can be divided into full duals and partial duals on the basis of the medicaid benefits that people are eligible to receive. The term medicaremedicaid enrollee is synonymous with the term dual eligible beneficiary which has been used in prior reports by cms and other organizations. Glossary of terms related to dualeligible beneficiaries.
The health and cost challenges of the dualeligible population are further complicated by the variation in coverage and payment policies offered by 50 separate and unique medicaid policies. Managed care plans for dualeligible beneficiaries medpac. The state mma file definition of medicaremedicaid enrollee implies concomitant enrollment in any given month in medicaid and medicare part a andor part b. What is medicare dual eligible and how do i qualify. List and definition of dual eligibles medicaremedicaid enrollees. The mmai is a groundbreaking joint effort to reform the way care is delivered to clients eligible for. Medicare and medicaid benefits and spending for dualeligible beneficiaries through contracts with. Age 21 and older and in need of communitybased long term care services for more than 120 days must enroll in a managed long term care plan or other care coordination model. Dual eligibles are lowincome individuals who are eligible for both medicare and medicaid bene.
Dual eligibles on the rise the dualeligible population is large and growing rapidly currently, there are more than 9. Trends in dualeligible population composition, spending, and service use. Model of care moc specific goals and objectives for the snp population including conducting the. Medicaid only dual eligibles non qmb, slmb, qdwi, qi1, or qi2 these individuals are entitled to medicare part a andor part b and are eligible for full.
Less than 30% of those dual eligibles are enrolled in a medicare advantage or special needs plan dsnp. These patterns fit with our expectations that for most indicators the hcbs qi denominator population would experience higher rates of the qi events than the medicaid population overall, and likewise that the hcbs dual eligible subpopulation. Dualeligible beneficiaries are those who qualify for both medicare and medicaid. Work is underway at a number of agencies to identify models that provide more effective and efficient care for people with adadrd.
Unfortunately, dual eligible beneficiaries are often poorer in health and require more expensive treatment options. Defining medicaremedicaid enrollees1 in cms data sources a. Medicare for the coverage of most preventive, primary, and acute health care services and prescription drugs, and medicaid for the coverage of ltss, certain behavioral health services, and medicare premiums and costsharing. The dual eligible population is diverse, and includes many beneficiaries with multiple chronic illnesses, dementia and other forms of cognitive impairment, physical. Definitions of various terms used in this report appear in the glossary at the end of the report. Dual eligible special needs plans dsnps model of care. These patients account for 16% and 15% of medicare and medicaid beneficiaries respectively, but make up 27% and 39% of costs. Target populations must be specifically defined, as the definition determines whether sampled cases are eligible or ineligible for the survey. Quality of care is also an important concern in the care of the dual eligible population. Defining medicaremedicaid enrollees in cms data sources. Mental health and substance use disorders are defined based on the. Dual eligible population duals in medicaid transformation a guide to how the dual experience is captured what is a dual or dual eligible person. Dual eligible beneficiaries are a varied group, but many have extensive health care needs, stemming from multiple illnesses and disabilities.
This population is diverse and includes individuals with multiple chronic conditions, physical disabilities, and cognitive. An analysis of selected mental health conditions among maryland fullbenefit dualeligible beneficiaries overview at the request of the maryland department of health and mental hygiene dhmh, the hilltop institute conducted a series of analyses on the health care utilization of marylands fullbenefit dualeligible beneficiaries. As long as you meet the federal qualifications for medicare eligibility and the statespecific qualifications for medicaid eligibility, you will qualify as a dual eligible. Learn the ins and outs of the dual eligible special needs plan today. Dual eligibles are a diverse population in terms of need forand use of medical and nonmedical services, but as a group they are poorer and sicker than medicare and medicaid beneficiaries who are not dually eligible. This transition will allow time for the department, beneficiaries, health plans and providers to adjust to the capitated delivery system prior to expanding to fulldual eligible beneficiaries. A total of 23 states and the district of columbia use this eligibility pathway, which accounts for about 15 percent of full. All dual eligible beneficiaries are low income, but those in dsnps tended to have somewhat different demographic characteristics relative to those dual eligible beneficiaries in other ma plans. This page highlights some key resources examining the dual eligible population and provides you with the standard search result page for a sitewide search on the dual eligible tag. The geographic and temporal characteristics of the target population need to be delineated, as well as types of units being included. An analysis of selected mental health conditions among.
They are often in poor health and among the most costly patients to both programs. Medicare and medicaid benefits and spending for dualeligible beneficiaries through. The project, also known as the demonstration, is testing an innovative payment and service delivery model to improve coordination of services for dual eligibles, enhance quality of care, and reduce costs for both the. Any state that we can have dual citizens on our dsnp and separate agpanthem medicaid note. The full dual subgroup increased by 6% during the 20052010 timeframe. Scan health plan president to discuss serving the dual. The term dual or dual eligible refers to people who qualify for both medicaid and medicare. Dualeligible beneficiaries vary, however, in the amount of medicaid benefits for which they qualify. Ninetyfour percent of members are dually eligible for medicare and medicaid and the remaining 6 percent of members are eligible for medicaid only. Dual eligibles, chronic conditions, and functional impairment. Mar 18, 20 mltc mandatory target population the 2011 budget legislation requires that all dual eligible medicaid and medicare who are.
For medicaid benefits, beneficiaries generally enroll in their states medicaid ffs program or a medicaid managed care plan administered by an mco under contract with the state. List and definition of dual eligibles medicaremedicaid. Approximately 12 million americans are dual eligible, representing 20% of the medicare population. Apr 19, 2016 individuals identified as harp eligible must be offered care management through statedesignated health homes.
Development of quality indicators for the home and community. Pdf improved care coordination for dual eligibles has the potential to reduce hospitalizations and eliminate duplicative services. Dually eligible beneficiaries under medicare and medicaid cms. Cms, dual eligible categories and list and definition of dual eligibles, 23. Will dhcs revise apl 18020 to allow dual eligibles in this population to be eligible for the sb 1004apl 18020 benefit. Dual eligible beneficiaries receive both medicare and medicaid benefits by virtue of their age or disability and low incomes. On february 22, 20, the illinois department of healthcare and family services hfs received approval from the federal centers for medicare and medicaid services cms to jointly implement the medicaremedicaid alignment initiative mmai. Dual eligible beneficiaries are more likely than non dual eligible beneficiaries to be under age 65 and disabled. Oct 21, 2016 dual eligibles are among the most vulnerable of our fellow citizens and historically among the highest utilizers of healthcare services, says roth. They make up 18 percent of the medicaid population but represent 46 percent of medicaid expenditures. For example, dual eligibles are automatically enrolled into the lowincome subsidy. Dualeligible beneficiaries of medicare and medicaid.
Over our 40 year history, scan has worked to build the programs and expertise required to support the dually eligible and actively promote a thoughtful public policy discussion to how to. Sep, 2012 about 9 percent of the dual eligible population is enrolled in 322 medicare dual eligible special needs plans dsnp, a type of medicare advantage ma plan. State allows duals to be enrolled in both a medicare dsnp and medicaid managed care plan administered by anthem amerigroup, so dual may be enrolled in both plans separately. Dual eligible special needs plans dsnp a guide for agents. The dual eligible population is far from homogeneous. Medicare is the primary payer for doctors, hospitals, posthospitalization skilled nursing, home health care and prescription drug costs. Dually eligible individuals must navigate two separate programs. As for question 9, ltc facilities are by definition, institutions. People eligible for both medicare and medicaid benefitsknown as dualeligible beneficiariesare a varied group, but many have extensive health care needs and account for a disproportionate share of spending on medicare and medicaid. Approximately 11 million americans are dual eligible, representing 20% of the medicare population. Enrollment of eligible individuals in the rest of nys will begin in july 2016.
1394 841 865 123 84 102 1367 771 326 1025 1632 681 1381 234 1233 1491 936 1248 679 1261 58 598 1144 1211 1279 1556 832 763 1191 1632 73 1065 28 24 493 801 209