Quantifying Dual Eligible Beneficiaries in Medicaid MLTSS and FFS Medicare
Dual-eligible beneficiaries often must navigate two uncoordinated, complex programs: Medicare and Medicaid. This lack of coordination creates barriers to access, poor health outcomes, and cost-shifting between the payers. It also creates considerable stress for dual eligible beneficiaries and their caregivers. Policymakers have sought to address this fragmentation through integrated programs, but no public data are readily available on dual eligibles with access to these programs who choose to remain in Traditional Fee-for-Service (FFS) Medicare. Equipped with information on dual eligible beneficiary enrollment, state and federal policymakers, researchers, providers, and other stakeholders would be better able to target education, care management solutions, program designs, and supports to these individuals.
ATI estimated the number of dual-eligible beneficiaries in Medicaid managed long-term services and supports (MLTSS) programs but remaining in Medicare FFS. We focused on this program type given its prevalence among integrated solutions that have emerged in recent years. We initially evaluated 18 states but for 2 states, New York and Illinois, data were insufficient and/or not reflective of recent program redesign. Medicaid data were obtained through state and CMS websites as well as direct communication with state Medicaid agencies; Medicare data were obtained through a combination of CMS enrollment reports, public Accountable Care Organization (ACO) data, and the Master Beneficiary Summary File. We applied assumptions to the underlying data based on state program design (e.g., to reflect Medicaid managed care carve-outs or limited county availability). Across the 16 analyzed states, 1.4 million dual eligible beneficiaries are enrolled in MLTSS with FFS Medicare. Of duals enrolled in MLTSS, 44% are in FFS Medicare. An estimated 233,000, or 17%, of those are enrolled in a Medicare ACO.
A considerable number of dual eligible beneficiaries with access to integrated programs remain in Medicare FFS, suggesting an opportunity for targeted education and program design. Additionally, data on dual eligible beneficiary enrollment should be more readily available and not limited to entities purchasing Medicaid and Medicare data access through the CMS data vendor. Quantifying this population through public and private data sources requires considerable data assumptions, estimation, and programming, suggesting it would be difficult for states, providers, and other stakeholders developing programs that meet these individuals’ needs.