PEOPLE ENROLLED IN MEDICARE AND MEDICAID

In 2008, there were 9.2 million individuals eligible for both the Medicare and Medicaid programs.[1]  Medicare-Medicaid enrollees, “dual eligibles,” are among the most chronically ill and costly individuals enrolled in both the Medicare and Medicaid programs, with many having multiple chronic conditions and/or long-term care needs.  More than half of Medicare-Medicaid enrollees have incomes below the poverty line[2] compared with 8 percent of other Medicare beneficiaries.[3]  Forty-three percent of Medicare-Medicaid enrollees have at least one mental or cognitive impairment,[4] while 60 percent have multiple chronic conditions.[5]  Nineteen percent live in institutional settings compared to only 3 percent of Medicare beneficiaries who are not also eligible for Medicaid.⁵  This group must navigate two separate programs: Medicare for coverage of basic acute health care services and drugs, and Medicaid for coverage of long-term care supports and services, and help with Medicare premiums and cost-sharing. 

 

Medicare-Medicaid enrollees account for a disproportionately large share of expenditures in both the Medicare and Medicaid programs: accounting for 16 percent of Medicare enrollees, yet 27 percent of Medicare spending in 2006.[6]  In Medicaid, they comprised only 15 percent of enrollees but represented 39 percent of Medicaid spending in 2007.[7]  

 

Share of Medicaid Enrollment and Costs Associated with Medicare-Medicaid Enrollees

Medicare-Medicaid enrollees account for approximately $120 billion in Federal and State spending – about twice as much as Medicaid spent on the 29 million children it covered.  States alone spent over $50 billion in 2007 to support the uncovered health and long-term care costs of people enrolled in Medicare.  The Medicaid spending on Medicare-Medicaid enrollees was $15,459 in 2007, over six times higher than the comparable cost of a non-disabled adult covered by Medicaid ($2,541). This spending mostly reflects the significant costs of a population with low income and high health care needs; however, there is opportunity for savings through improved care coordination, simplification, and the alignment of Medicare and Medicaid rules.  

 

Spending on Medicare-Medicaid enrollees varies by State (see attached table).  It accounts for more than 40 percent of all combined federal and state Medicaid spending in 26 states, including more than half of such spending in four States   and no less than a quarter of spending in any State. 

 

Medicare-Medicaid enrollees are a higher cost population in Medicaid than other enrollees.   For example, in one state the average Medicaid spending for someone also enrolled in Medicare is ten times higher than average Medicaid spending on a non-disabled adult Medicaid enrollee.  

Medicare-Medicaid Coordination Office.  Created by the Affordable Care Act, the new Federal Coordinated Health Care Office (the Medicare-Medicaid Coordination Office) works to improve coordination between the Federal government and States for Medicare-Medicaid enrollees in order to ensure full access to covered services in both programs and high quality care.  The Office is moving forward on improving access, coordination, and cost of care with a focus in three major areas:  Program Alignment, Data and Analytics, and Models and Demonstrations.  To date, the Medicare-Medicaid Coordination Office has:

·       Selected 15 States to receive contracts for up to $1 million each to design new integrated care models for people enrolled in Medicare and Medicaid.   The 15 States are California , Colorado , Connecticut , Massachusetts , Michigan , Minnesota , New York , North Carolina , Oklahoma , Oregon , South Carolina , Tennessee , Vermont , Washington and Wisconsin . 

·       Initiated the process of creating a technical assistance center to help all States better meet the needs of these complex, high-cost beneficiaries. 

·       Launched the Initiative to Align the Medicare and Medicaid Programs.  The goal of this initiative is eliminate unnecessary and inefficient conflicts in the regulatory, statutory, and policy requirements of the two programs, where feasible.  

·       Announced the availability of more timely Medicare Parts A, B, and D claims data for States to help them improve their care coordination for low-income seniors and people with disabilities who are enrolled in Medicare and Medicaid. 

 

In addition to this work, the Medicare-Medicaid Coordination Office sent a letter to Congress on March 1, 2011, to report on the steps that the Office has taken, and will take, to achieve the goals and responsibilities set forth in the Affordable Care Act. For more information, please visit:   www.cms.gov/dualeligible/downloads/HHSDualsOfficeLettertoCongress.pdf  

 

CMS Care Coordination Efforts.  The work of the Medicare-Medicaid Coordination Office is being done in concert with significant reforms across the health care delivery system that will improve the coordination of care for all patients, which will improve the care received by these low-income beneficiaries:

• Partnership for Patients: Using funds from the Affordable Care Act, the Department of Health and Human Services has announced a $1 billion investment in patient safety.  These funds will be used to build on existing patient safety initiatives that are now improving coordination of care and providing savings in limited settings.  The Partnership will eventually take these efforts to scale, which could save tens of thousands of lives, prevent millions of preventable injuries, and save billions of dollars.
• Medicaid Health Homes: Starting this year, states can receive additional federal support for creating “health homes” for beneficiaries who have chronic conditions.  Under the “health home” option, beneficiaries with complex medical needs can receive coordinated care, help transitioning from one health care setting to another, and other support.  Under this state plan option created by the Affordable Care Act, States can receive two years of a 90 percent federal match rate for care coordination and other services offered as part of a health home.
• Accountable Care Organizations (ACOs): CMS has proposed rules to allow health care providers to form ACOs, where they will work together to coordinate care for patients, and be paid for the quality of care they deliver across settings.  This has the potential to result in shared savings payments to providers and savings to Medicare.