Dual Medicare-Medicaid Enrollees

People dually enrolled in Medicare and Medicaid constitute one of the nation’s most vulnerable populations. But how much do we really know about them? Federal and state policymakers have long recognized the importance of understanding and addressing the complex care needs of people enrolled in both programs, a group sometimes referred to as dual enrollees. In contrast to those who are eligible for only one of these programs based on the criteria of age, disability, or low income, dual enrollees face a combination of elevated chronic disease prevalence, disability, and poverty. Concerns about the general lack of coordination among providers drive much of the current focus of patient-centered care models, but these concerns are especially acute for dual enrollees, for whom unmet needs for long-term services and supports can exacerbate acute and chronic health problems, leading to even greater need for long-term services and supports.

Beyond the potential for suboptimal quality of care caused by a lack of insurance benefit coordination, the split financing of the two programs also raises the possibilities of duplicative services and unnecessary spending. Since 2013, the Centers for Medicare & Medicaid Services (CMS) and 13 states have been fielding demonstration programs to integrate the financing and delivery of care for this population. Beyond the demonstration, CMS has also incentivized other models of integration through the Medicare Advantage program to target dual enrollees.

Four Sets of Resources for Understanding and Addressing the Needs of Dual Enrollees

Urban Institute staff contribute to a wide variety of research to help policymakers and administrators understand dual enrollees. This body of research spans descriptive studies, quantitative evaluation work, technical data issues, and policy analyses aimed at improving the financing and delivery of care for dual enrollees. Here you will find our resources divided into four sections:

Descriptive Features of Dual Enrollees and Eligible Nonenrollees

Dual enrollees generate significant interest for many reasons; however, they are not a homogenous group. Descriptive analyses on dual enrollees, as well as dually eligible nonenrollees, shed light on the many distinctive and cross-cutting features of this population.

Medicare Savings Program Enrollees and Eligible Non-Enrollees
Caswell, Kyle J., and Timothy Waidmann. 2017
Report for Medicaid and CHIP Payment and Access Commission (MACPAC)
Urban Institute and MACPAC, Washington, DC

This analysis links data from the Survey of Income and Program Participation with administrative data from the Medicaid Statistical Information System to estimate program-specific participation rates for the different types of Medicare Savings Programs. The analysis identifies individual and geographic sources of variation in those rates.

Rates and Timing of Medicaid Enrollment among Older Americans
Spillman, Brenda, and Timothy A. Waidmann. 2014
Final Report to the Office of the Assistant Secretary of Planning and Evaluation (ASPE)
Urban Institute and ASPE, Washington, DC

This study provides estimates on the prevalence and predictors of Medicaid enrollment in the older population, using multiple years of Medicaid and other administrative data linked to the 2004 National Long-Term Care Survey. Predictors include community residency, nursing home entry, income, and assets.

The Diversity of Dual Eligible Beneficiaries: An Examination of Services and Spending for People Eligible for Both Medicaid and Medicare. (External link: leave urban.org to access)
Coughlin, Teresa A., Timothy A. Waidmann, Lokendra Phadera, Rachel Garfield, and Barbara Lyons. 2012
Kaiser Commission on Medicaid and the Uninsured, Washington, DC

We present findings based on an analysis of linked 2007 Medicare and Medicaid data. The study compares the characteristics, health status, health care utilization, and health care spending of dual enrollees with those of the Medicare population not dually enrolled in Medicaid.

Where Does the Burden Lie? Medicaid and Medicare Spending for Dual Eligible Beneficiaries. (External link: leave urban.org to access)
Coughlin, Teresa A., Timothy A. Waidmann, and Molly O’Malley Watts. 2009
Issue Paper No. 7895
Kaiser Commission on Medicaid and the Uninsured , Washington, DC

We analyze the demographic and health characteristics of the dually eligible population and their patterns of health care utilization and spending under both the Medicare and Medicaid programs. These findings are based on an analysis of national survey data linked to Medicare and Medicaid administrative data in 2003.

Integrated Care for Dual Enrollees

Dual enrollment in Medicare and Medicaid is uniquely challenging for enrollees, because Medicare and Medicaid are separate government health insurance programs with distinct benefits and rules. Increasingly, efforts to streamline and integrate insurance benefits across the two programs have expanded, with the goals of improving enrollees’ experiences and health outcomes and possibly reducing overall health care expenditures. Examples of new and more integrated health insurance products for dual enrollees include Medicare-Medicaid Plans offered through the CMS Financial Alignment Initiative (FAI) demonstrations, Medicare Advantage Special Needs Plans, Dual Eligible Special Needs Plans, and Fully Integrated Dual Eligible Special Needs Plans and others.

Urban Institute staff contribute to the knowledge of integrated plans’ effectiveness through their participation in formal CMS FAI demonstration evaluations. Urban researchers are also currently working on separate evaluations of the FAI demonstrations in Massachusetts and Washington State using alternative methodologies.

Assessment of the Literature on Integrated Care Models for People Dually Enrolled in Medicare and Medicaid: Approaches Used and Priorities for Future Research
Barrie Smith, Laura, Timothy A. Waidmann, and Kyle J. Caswell. 2021
Urban Institute, Washington, DC

This literature review examines existing research that quantitatively evaluates whether, or the degree to which, integrated plans for dual enrollees meet their objectives. In doing so, we broadly categorize existing studies by methodologies employed and identify potential opportunities for future studies to measure the causal effects of integrated plans.

Financial Alignment Initiative demonstration evaluation reports (External link: leave urban.org to access)
CMS is testing FAI models to better align Medicare and Medicaid financing and to integrate primary care, acute care, behavioral health, and long-term services and supports for dual enrollees. This resource provides links to the FAI evaluation reports.

Dual Medicare-Medicaid Enrollees and T-MSIS Analytic Files (TAF) Data Quality

The data on dual enrollees is improving but more work is needed. On November 8, 2020, CMS announced the availability of new Medicaid administrative data files, namely the Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF). Key resources are available by topic and state to improve the utility and quality of these new data files, including TAF data quality assessments and a TAF data quality website, DQ ATLAS. These resources focus on the Medicaid population more generally. However, in three reports, we contribute to knowledge of the TAF’s data quality by specifically focusing on issues related to dual enrollees. Medicare-Medicaid dual enrollees represent a minority of Medicaid enrollees overall, meaning data quality issues identified in the more general Medicaid population may not apply to dual enrollees. Also, some TAF data features and data quality questions are specific to dual enrollees.

Dual Medicare-Medicaid Enrollment and Integrated Plan Identification: T-MSIS Analytic Files (TAF) Data Quality
Caswell, Kyle J., and Timothy A. Waidmann. 2021
Urban Institute, Washington, DC

This report focuses on the quality of the TAF’s dual enrollment data, including its ability to identify integrated plan enrollees.

Measuring Medicaid Service Utilization among Dual Medicare-Medicaid Enrollees Using Fee-for-Service and Encounter Claims: T-MSIS Analytic Files (TAF) Data Quality
Caswell, Kyle J., Timothy A. Waidmann, and Keqin Wei. 2021
Urban Institute, Washington, DC

This analysis focuses on the quality of the TAF’s medical care utilization data among services where Medicaid is typically the primary payer among dual enrollees.

Medicaid Spending on Managed-Care Capitation and Fee-for-Service Claims among Dual Medicare-Medicaid Enrollees: T-MSIS Analytic Files Data Quality
Caswell, Kyle J., Timothy A. Waidmann, and Keqin Wei. 2021
Urban Institute, Washington, DC

This study examines the quality of the TAF’s Medicaid spending data among dual enrollees.

Policy

In addition to demonstration programs, several policy proposals have the potential to strengthen financing of the Medicare and Medicaid programs, support the integration of Medicare and Medicaid, and improve the health and well-being of dual enrollees. These policy proposals address new or modified approaches to targeting dual enrollees most in need of coordinated care, reforming Medicare Savings Programs, and changing Medicare’s eligibility age.

The Effect on States of Increasing the Medicare Eligibility Age
Waidmann, Timothy A., and Emily Lawton. 2015.
Urban Institute, Washington, DC

Proposals to raise the Medicare eligibility age may have unintended consequences for state government finances. In this brief, we estimate the number of dual enrollees in each state and the amount of current Medicare spending for these individuals that could be shifted to state Medicaid programs.

Among Dual Eligibles, Identifying the Highest Cost Individuals Could Help in Crafting More Targeted and Effective Responses. (External link: leave urban.org to access)
Coughlin, Teresa A., Timothy A. Waidmann, and Lokendra Phadera. 2012
Health Affairs 31, no. 5

We examine the medical care costs and service utilization associated with dual eligibles in 2007 and find that 40 percent had lower average per capita spending than Medicare beneficiaries not dually enrolled in Medicaid. Dual eligibles with very high health care costs and complex care needs are a relatively small subgroup.

Policy Options to Improve the Performance of Low Income Subsidy Programs for Medicare Beneficiaries.
Zuckerman, Stephen, Baoping Shang, and Timothy A. Waidmann. 2012
Washington, DC, Urban Institute

In this report, we consider policy options to reform Medicare's low-income subsidies to better align with Affordable Care Act provisions. We estimate a significant simplification in low-income protection and cost-sharing rules could greatly reduce burdens on beneficiaries with the lowest incomes and greatest health care needs.

Refocusing Responsibility for Dual Eligibles: Why Medicare Should Take the Lead.
Feder, Judy, Lisa Clemans-Cope, Teresa A. Coughlin, John Holahan, and Timothy A. Waidmann. 2011
Urban Institute and Robert Wood Johnson Foundation, Washington, DC

In our analysis, we explain why policymakers rely far too heavily on states to control costs and assign responsibility for dual eligibles. Potential savings come from better management of Medicare-financed acute and postacute care services.

Improving Care for Dual Eligibles through Innovations in Financing(External link: leave urban.org to access)
Clemans-Cope, Lisa, and Timothy A. Waidmann. 2011
New England Journal of Medicine 365:e21

Despite rising costs, Medicaid and Medicare had shown a striking lack of leadership in care coordination for dual eligibles as of 2011. We suggest ways in which CMS's proposed models could be modified to improve both the quality and cost effectiveness of care for dual eligibles.

Medicare Savings Programs: Analyzing Options for Expanding Eligibility. (External link: leave urban.org to access)
Zuckerman, Stephen, Baoping Shang, and Timothy A. Waidmann. 2009.
Inquiry 46 (4): 391–404.

We consider changes in eligibility that would better align eligibility for the Medicare Savings Programs with that for receiving low-income subsidies for the Medicare Part D drug benefit. These changes would make more people eligible for the Medicare Savings Programs and could encourage greater participation.