Policymakers often overlook or disregard the problems people may face when they try to enroll or stay enrolled in public programs or to get the care they need. Issues around Medicare and Medicaid enrollments and appeals are legion and can run the gamut from minor one-time annoyances to recurrent bureaucratic nightmares.
Download PDFMedicaid is financed and administered through a federal-state partnership. Under current law, the federal government matches state Medicaid spending based on a statutory formula, without a pre-set limit. If state spending increases, for example due to increased enrollment or unexpectedly high program costs, then federal spending increases as well.
Download PDFWith the passage of HR 1, Congress is cutting around $1 trillion from Medicaid over the course of the next 10 years. The cuts will affect Medicaid at every level, restricting eligibility and enrollment, driving up the cost of covered services for beneficiaries and states, and damaging the health care system nationwide. These cuts harm the people who rely on the program, including millions of older adults and people with disabilities who are dually eligible for Medicare and Medicaid, as well as people nearing Medicare eligibility who have coverage through expansion Medicaid.
Download PDFMany states have expanded Medicaid coverage and care through Medicaid “Section 1115” waivers, but some states are inclined to move in the opposite direction, to limit eligibility or restrict coverage.
Download PDFIn <em>Improving Care Coordination</em>, the case study contrasts the consequences of weak versus effective care coordination across Medicare and Medicaid. Ms. T’s experience shows how limited integration and inadequate plan support can lead to improper billing, unresolved provider issues, and ultimately a disruption in care when her therapist drops her. In contrast, Mr. Y’s story demonstrates how strong care coordination within a fully integrated plan can proactively protect access to critical services, including uninterrupted 24-hour home care. Together, these examples highlight the essential role of care coordination in reducing administrative burden, preventing care disruptions, and improving outcomes for dually eligible individuals.
Download PDFIn <em>Stopping Coverage Loss and Disruption</em>, the case study focuses on “churn,” or the loss and regaining of coverage, and how it can interrupt care and destabilize integrated plans. Mrs. E’s experience shows how administrative errors in Medicaid recertification can lead to the loss of both Medicaid and integrated D-SNP coverage, resulting in higher costs, missed care, and fragmented services. Mr. V’s story highlights how misleading marketing and confusion about plan options can push beneficiaries out of highly integrated coverage into less coordinated plans, putting critical services like home care at risk. Together, these cases underscore the need for stronger safeguards, clearer communication, and streamlined processes to prevent unnecessary coverage disruptions and protect access to care.
Download PDFIn <em>Closing Gaps in Benefits and Services</em>, the case study examines how differences in Medicare and Medicaid coverage rules, vendors, and plan structures can create barriers to essential services like transportation. Mrs. W’s experience shows how limited integration and misleading expectations around supplemental benefits can leave beneficiaries with less access to care than before, while Mr. L’s story demonstrates how more aligned or integrated plans can simplify access and reduce administrative burdens. Together, these examples highlight the need for clearer plan information, stronger oversight of supplemental benefits, and greater alignment between Medicare and Medicaid to ensure beneficiaries receive the services they need.
Download PDFIn <em>Fixing the Appeals Process</em>, the case study contrasts two beneficiary experiences to show how fragmented versus integrated systems impact access to care. Mr. H’s story illustrates the confusion and delays that arise when Medicare and Medicaid appeals operate separately, leaving him caught between two plans and unsure how to secure coverage for a medically necessary wheelchair feature. In contrast, Mrs. Z benefits from an integrated appeals system that streamlines decision-making and reduces administrative burden, ultimately improving her access to needed services. Together, these examples underscore the importance of aligning Medicare and Medicaid processes and inform policy recommendations aimed at simplifying appeals and strengthening care coordination.
Download PDFWithout Medicaid, many Medicare enrollees—especially those with limited income—would struggle to afford care, risking their health or having to choose between medical care and housing, food and other essentials. Cutting Medicaid would directly harm millions of Medicare enrollees and increase costs for the Medicare program and state budgets.
Download PDFMedicare guarantees access to health care for older adults and people with disabilities. Together with the Affordable Care Act (ACA) and Medicaid, Medicare builds health security and well-being for New Yorkers of all ages. Any changes to these programs, whether at the state or federal level, must aim for healthier people, better care, and smarter spending—not paying more for less.
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