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Improving Health For People Dually Eligible For Medicare And Medicaid

by AHIP

June 26, 2018

Who Are Dually Eligible Individuals?

People who are eligible for both Medicare and Medicaid are called Medicare-Medicaid dual eligibles. They are particularly at risk in terms of their health and financial security, and therefore, require special support and services to help them achieve better health and peace of mind. Compared with most Medicare enrollees, they typically have more chronic conditions and greater levels of physical disabilities, cognitive impairments, and serious mental illness.

While dually eligible individuals make up about 20 percent of total Medicare enrollment and 15 percent of Medicaid enrollment, approximately 35 percent of the total expenses for both programs goes toward their costs for care.

How Do Medicare and Medicaid Work Together?

Medicare is the primary payer for dually eligible individuals, covering costs for doctor visits, hospital care, skilled nursing, home health, and prescription drugs.

Medicaid coverage “wraps around” Medicare for dually eligible individuals—that is, it picks up the costs that Medicare may not cover. Medicaid may cover Medicare cost sharing, including deductibles and coinsurance. Medicaid also covers long-term nursing home expenses, personal care in the home, and certain supportive services not covered by Medicare.

But the two programs were not designed to work together, and Medicare and Medicaid providers frequently work in isolation with no clear picture of all the care and services a dual eligible person may be receiving. This leads to fragmented, uncoordinated care and duplication of services, with little focus on the whole person.

What Are Medicare-Medicaid Plans?

Medicare-Medicaid Plans (MMPs) are health plans that contract with both the federal government and state Medicaid agencies to serve dually eligible individuals through Financial Alignment Demonstrations. The first demonstration began in Massachusetts in 2014. As of January 2018, 50 Medicare-Medicaid Plans serve 383,000 people through demonstrations in nine states.  Medicare-Medicaid Plans are the most integrated model for serving dually eligible individuals in a single health plan, coordinating care and services through person-centered care plans. These individualized play-books tailor care and services specifically to the needs of each Medicare-Medicaid Plan enrollee.

How Have Medicare-Medicaid Plans Helped Dual Eligible Enrollees?

Medicare-Medicaid Plans emphasize primary care and disease management. They work to help people who want to maintain their independence and can safely live in their community stay out of nursing homes. This can lead to better health and quality of life, which in turn reduces in emergency room visits and hospitalizations—saving real money for federal and state governments and taxpayers.

Below we share stories about real Medicare-Medicaid Plan members, whose health plans have made a difference in their lives.*

Sarah’s Story

Like many dually eligible individuals, Sarah joined her Medicare-Medicaid Plan in Massachusetts with complex health care needs, lots of trips to emergency rooms and hospitals, and few connections to primary health care and community resources. Sarah had multiple chronic conditions and a history of homelessness. She was in and out of the hospital almost weekly, had difficulty understanding her discharge instructions, and did not follow up with her care.

Given these complex medical needs, when Sarah enrolled, her Medicare-Medicaid Plan designated Gretchen, a registered nurse, as Sarah’s care partner. Gretchen met Sarah at the hospital to plan for her discharge and later visited Sarah at home to learn more about her needs and goals. Gretchen also went with Sarah to a primary care doctor appointment and to see a specialist for the first time. Gretchen worked with Sarah’s physicians to simplify her medications and medication schedule, which revolutionized Sarah’s ability to manage her conditions.

Gretchen started visiting Sarah every Tuesday morning to establish a reliable and trusting relationship. She set up an at-home medication administration system with helpful visual cues and made sure the medications were refilled each week. Gretchen also connected Sarah with a dentist, an eye doctor, and new glasses, and set her up with a therapist to visit her at home. The Medicare-Medicaid Plan’s behavioral health team also met with Sarah at home and helped her connect with community resources and home-delivered meals.

Due to her Medicare-Medicaid Plan’s efforts, Sarah’s medical conditions are now better controlled and her hospital stays dropped by half. She has access to social and support systems on a regular recurring basis, something she wasn’t able to do when she was in the hospital so frequently. And most importantly, she feels proud of the positive gains she has made in her own health and quality of life.

John’s Story

John is a member of a Medicare-Medicaid Plan in Texas. He has a physical disability and his wife has Parkinson’s disease. John had been using a prescription opioid to cope with his pain and stress, and has a history of multiple ER visits due to chest and abdominal pain and headaches.

Since he began working with his Medicare-Medicaid Plan care team, John has started medication-assisted treatment, using Suboxone to manage his opioid dependence. He works with a therapist to develop skills for coping with stress, talks regularly by phone with a nurse care coach to support his health goals, and has regular in-person visits with a community care coordinator.

John has also begun exercising. “I’m finally putting myself first … I am out walking and starting to lose weight!” he says. With the help and support of consistent care management and coordination from his Medicare-Medicaid Plan’s care team, John has been opioid free for over two months.

Allison’s Story

Allison lives in Ohio and joined a Medicare-Medicaid Plan as a nursing facility resident. She has diabetes, congestive heart failure, peripheral vascular disease, hypertension, and osteoarthritis. She was anxious to move back into her apartment, which she had not lived in for three years.

With the help of Kevin, her Medicare-Medicaid Plan care manager, Allison was able to achieve her goal of moving out of the nursing facility and back to her apartment. Preparing for her move, Kevin arranged a home evaluation and identified household items and home modifications Allison would need, including a walker, shower bar, lift chair, and a new bed. Kevin also arranged for visits by a home health aide, weekly skilled nurse visits, and home-delivered meals. He also scheduled transportation to take Allison to her medical appointments.

The nursing facility had been resistant to transitioning Allison back to the community until they saw the support Allison would receive and the arrangements being made in the apartment. She had a successful home evaluation and impressed everyone with how well she could maneuver in her apartment. Teamwork between Allison, her care manager, and the nursing facility allowed her to move back home.

Elizabeth’s Story

Elizabeth is a California Medicare-Medicaid Plan member with depression, rheumatoid arthritis, and fibromyalgia. Frank, Elizabeth’s Medicare-Medicaid Plan service coordinator, determined she was living in pain, had unmet medical needs, and was having problems carrying out basic activities in her daily life. She also lacked basic home necessities, including cooking supplies to safely prepare food for herself.

Frank developed a personalized service coordination plan to connect Elizabeth with medical and social services and supports. Frank helped Elizabeth schedule an appointment with a pain specialist. He also helped secure an in-home attendant and needed supportive equipment, including a shower bench and toilet riser, as well as incontinence supplies.

Frank coordinated with local community organizations to provide donated furniture and cooking supplies as well. After unsuccessful attempts to find volunteers to assist with moving the furniture into the Elizabeth’s home, Frank even went the extra mile to coordinate with a group of his colleagues to use Medicare-Medicaid Plan staff and vehicles to deliver the donated furniture to Elizabeth. Through her Medicare-Medicaid Plan’s efforts, Elizabeth’s quality of life improved and she can now live more comfortably in her home.

* While their stories are true, names have been changed to protect their privacy

Visit our issue pages to learn more about the Medicare and Medicaid programs and how health insurance providers are serving patients across the country.