Dual Eligibles: The Basics

1
Dual Eligibles The Basics

• Barbara Lyons, Ph.D.
• Director, Kaiser Commission on Medicaid and the
  Uninsured
• Senior Vice President, Henry J. Kaiser Family
  Foundation
• For
• Alliance for Health Reform
• Washington, DC
• June 3, 2011

2
9 Million Dual Eligibles are Covered by Both
Medicare and Medicaid
Dual Eligibles 9 Million
Total Medicare Beneficiaries, 2007 43 million
Total Medicaid Beneficiaries, 2007 58 million
Source Kaiser Family Foundation analysis of
Medicare Current Beneficiary Survey, 2007, and
Urban Institute estimates based on data from the
2007 MSIS and CMS Form 64.
3
Medicaid Supplements Medicare for Dual Eligibles

• Nine million Medicare beneficiaries, including
  5.5 million seniors and 3.4 million disabled,
  receive help from Medicaid
• Medicare is a national program that provides
  coverage of medical services, including hospital,
  physician, prescription drugs, and limited
  post-acute care, but requires premium payments
  and cost-sharing (ie, hospital deductible 1,132
  annually Part B premium 115/month in 2011)
• Medicaid is a joint federal-state program that
  supplements Medicare for low-income beneficiaries
• Provides financial assistance with Medicare
  premiums and deductibles and co-insurance for
  Medicare-covered services
• Medicaid helps pay for services not covered by
  Medicare, such as hearing, vision and long-term
  care

4
How Do Dual Eligibles Qualify for Medicaid?

• For the poor States are generally required to
  cover individuals qualifying for SSI (income
  below 75 of poverty and 2,000 or less in assets
  for an individual) states have the option to
  cover individuals up to 100 of poverty
• For those with high medical or long-term care
  expenses, special eligibility and level of need
  rules apply
• 38 states allow individuals who need nursing home
  care to qualify up to 300 of the SSI level
  (2,022 per month for an individual), but require
  them to contribute most of their income to the
  cost
• 26 states have a medically needy program enabling
  individuals to spend-down
• Eligibility for home and community-based care is
  typically linked to nursing home standards
• Most dual eligibles qualify for full Medicaid
  benefits, while some qualify for more limited
  Medicaid assistance to help with Medicare
  premiums and cost sharing through Medicare
  Savings Programs

5
Dual Eligibles are Poorer and Sicker than Other
Medicare Beneficiaries, 2008
SOURCE Kaiser Family Foundation analysis of the
Medicare Current Beneficiary Survey 2008 Access
to Care File.
6
Dual Eligibles Use More Medicare Services Than
Other Medicare Beneficiaries, 2006
SOURCE Kaiser Family Foundation analysis of the
Medicare Current Beneficiary Survey Cost Use
File 2006.
7
Medicare Spending is Higher for Dual Eligibles
Living in LTC Facilities Than for Duals Living in
the Community, 2006
Share of Dual Eligibles
16
84
NOTE Excludes Medicare Advantage enrollees
spending. Excludes Medicare prescription drug
spending. Includes beneficiaries who were in
long-term care facilities as of January 1, 2006,
including those who died before the end of
2006. SOURCE Medicare spending and enrollment
estimates from Kaiser Family Foundation analysis
of the CMS Medicare Current Beneficiary Survey
Cost and Use File, 2006
8
Dual Eligibles Account for Disproportionate Share
of Spending in Medicare and Medicaid
Medicare FFS Enrollment, 2006 Total36 million
Medicare FFS Spending, 2006 Total299 billion
Medicaid Enrollment, 2007 Total58 million
Medicaid Spending, 2007 Total311 billion
SOURCE Medicare spending and enrollment
estimates from Kaiser Family Foundation analysis
of the CMS Medicare Current Beneficiary Survey
Cost and Use File, 2006 Medicaid spending and
enrollment estimates from Urban Institute
analysis of data from MSIS and CMS Form 64,
prepared for the Kaiser Commission on Medicaid
and the Uninsured, 2010.
9
Expenditures for Dual Eligibles as a Share of
Total Medicaid Spending, 2007
NH
VT
WA
ME
ND
MT
MN
MA
OR
NY
ID
WI
SD
RI
MI
CT
WY
PA
NJ
IA
OH
NE
IN
NV
WV
DE
IL
IL
UT
VA
MD
CO
MO
CA
KS
KY
NC
DC
TN
SC
OK
AR
AZ
NM
GA
AL
MS
TX
LA
AK
FL
HI
25-34 (13 states including DC)
35-42 (18 states)
US Average 39
43 or more (19 states)
NOTE For 2007, the data quality for the state of
AZ is not adequate to construct measures of
complete spending in the state. SOURCE Urban
Institute and Kaiser Commission on Medicaid and
the Uninsured estimates based on data from MSIS
2007.
10
Medicaid Expenditures for Dual Eligibles, FY 2007
Medicare Premiums and Co-insurance, 11
billion, 9.2
Home and Community-Based Services 28.3
billion 25.5
Medicare-Covered Services, 18 billion, 14.9
Long-Term Care, 84,5 billion 70.1
Other Acute, 5.6 billion 4.7
Institutional Care, 56.2 billion, 46.6
Prescribed Drugs, 1.4 billion, 1.1
Total Spending 120.5 billion
Source Urban Institute estimates based on data
from MSIS and CMS Form 64, prepared for the
Kaiser Commission on Medicaid and the Uninsured,
2010.
11
Home and Community Based Services as a Share of
Total Medicaid LTC Spending on Elderly Duals, 2007
NH
VT
WA
ME
ND
MT
MN
MA
OR
NY
ID
WI
SD
RI
MI
CT
WY
PA
NJ
IA
NE
OH
IN
NV
WV
DE
IL
IL
UT
VA
MD
CO
MO
CA
KS
KY
NC
DC
TN
SC
OK
AR
AZ
NM
GA
AL
MS
TX
LA
AK
FL
HI
5-10 (13 states)
11-18 (16 states)
11-24 (10 states)
US Average 23
25 or more (10 states including DC)
NOTE For 2007, the data quality for the state of
AZ is not adequate to construct measures of
complete spending in the state. SOURCE Urban
Institute and Kaiser Commission on Medicaid and
the Uninsured estimates based on data from MSIS
2007.
12
Looking Ahead

• Medicaid is an important adjunct to Medicare for
  many low-income Medicare beneficiaries providing
  financial protections and a fuller complement of
  medical and long-term care services.
• Because of their poorer health status and greater
  health needs, dual eligibles are an expensive
  population for both the Medicare and Medicaid
  programs.
• Fragmentation and lack of coordination between
  Medicare and Medicaid can be challenging for dual
  eligibles, their families, and providers and
  result in inefficient care.
• Federal and state budget pressures could impact
  Medicare and Medicaids role for dual eligibles.
• The ACA provides new opportunities to coordinate
  care delivery for dual eligibles through the
  Duals Office and Innovation Center and to promote
  community-based care for dual eligibles, but
  requires assuring beneficiary safeguards and
  accountability.