Toward Continuous and Comprehensive Coverage for Dual Eligibles

For people enrolled in both Medicare and Medicaid, dual eligibility should mean better access, more benefits, and streamlined processes. But the reality is often more disorganized and complicated as the system seems to work against people just trying to access and secure their coverage.

The Medicare Rights Center’s new case study series, Making Medicare and Medicaid Work Better Together, brings together stories from dual eligibles who faced interruptions and interference with their essential care due to inadequate integration across the programs. Each brief features two thematically linked client stories and provides federal and state policy recommendations to improve Medicare–Medicaid coordination.

Enrollment Churn

States conduct periodic eligibility checks on Medicaid beneficiaries and require them to renew their enrollment regularly. This means that short-term increases in income, late or incomplete paperwork, or administrative errors can lead to repeated disruptions in necessary care and benefits. According to data from the last decade, one in 10 Medicaid beneficiaries was disenrolled and then re-enrolled in Medicaid within a single year, and the average length of coverage was less than 10 months.

This cyclical loss and regaining of coverage is known as “churn,” and it is especially consequential for dual eligibles. An unexpected disenrollment from Medicaid disrupts not only their care—which for many includes ongoing long-term services and supports in the home—but also the financial assistance they need to pay for their coverage.

Mrs. E, whose story is included in Stopping Coverage Loss and Disruption, was disenrolled from Medicaid due to an administrative delay over which she had no control. She lost her Medicaid coverage—and with it, her Medicare Savings Program and Dual Special Needs Plan—when her recertification paperwork was not delivered in time. Though nothing about her financial situation had changed to make her ineligible for Medicaid, this administrative error and delays in processing her re-enrollment led to a three-month period during which she lost her regular coverage and incurred costs she could not afford.

Dual Special Needs Plans

Dual Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan that provide some increased coordination between a dually eligible beneficiary’s Medicare and Medicaid coverage. In order of increasing integration, the three types of D-SNPs are Coordination-Only (CO) D-SNPs, Highly Integrated Dual-Eligible (HIDE) SNPs, and Fully Integrated Dual-Eligible (FIDE) SNPs. Like other MA plans, coverage and costs of individual D-SNPs vary by provider and program.

D-SNPs are appealing to dually enrolled beneficiaries who find it difficult to navigate the separate systems of Medicare and Medicaid. And at their best, D-SNPs can integrate benefits, care management, and appeals processes, giving the beneficiary one locus to access both programs. But the variations in integration levels, not to mention D-SNP “lookalikes” also in the MA marketplace to lure people without providing any extra benefits, make the experience of shopping for a D-SNP much more complicated.

In Closing Gaps in Benefits and Services, Mrs. W’s experience with her Coordination-Only (CO) D-SNP highlights the ways in which D-SNPs with inadequate integration take advantage of beneficiary confusion. Mrs. W enrolled in a CO D-SNP that promised to coordinate her non-emergency medical transportation benefit with her Medicaid managed long-term care (MLTC) plan. She expected the D-SNP would make transportation more accessible with less work from her. But the CO D-SNP, which was operated by a different company than her MLTC plan, actually interfered with her existing transportation benefits. Put in a financially and medically difficult position after losing access to transportation, Mrs. W had to seek help to find a better-integrated D-SNP that could work with her MLTC plan and truly deliver on promised benefits.

Policy Directions

Current Medicare and Medicaid policies do not do enough to protect dually eligible people from the difficulties of disrupted and inaccessible care. A system that requires a beneficiary to be vigilant just to keep their health care coverage from being snatched away is not a functional system.

The Centers for Medicare and Medicaid Services (CMS) must improve informational and educational resources for beneficiaries while restricting predatory marketing from MA organizations. When beneficiaries are fully able to comprehend and trust information coming directly from Medicare and Medicaid, they are less likely to rely on self-interested sources who may put their care at risk. CMS should include clear information about D-SNPs—including details like levels of integration, supplemental benefits, and model of care—on Plan Finder and in plan documents like the Evidence of Coverage. States should work together with CMS to expand education for beneficiaries and providers, and they should move toward simplified recertification processes for Medicaid programs.

Aggressive marketing from MA organizations, one of the drivers of coverage loss and churn, must also be reined in. Increased oversight from CMS can hold plans accountable when they mislead beneficiaries and ensure that they are delivering on promised benefits. Systemically, the payment model for Medicare currently incentivizes MA organizations to drive up enrollment at all costs. Standardizing MA plan offerings and eliminating MA overpayment will reduce the use of interested marketers and brokers, reducing both beneficiary confusion and financial strain to the system.

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