As for question 9, ltc facilities are by definition, institutions. Medicare for the coverage of most preventive, primary, and acute health care services and prescription drugs, and medicaid for the coverage of ltss, certain behavioral health services, and medicare premiums and costsharing. Dually eligible beneficiaries under medicare and medicaid cms. Sep, 2012 about 9 percent of the dual eligible population is enrolled in 322 medicare dual eligible special needs plans dsnp, a type of medicare advantage ma plan. Population characteristics that may be relevant to the passive enrollment issue include the following. Dually eligible beneficiaries under medicare and medicaid. For example, dual eligibles are automatically enrolled into the lowincome subsidy. In 2012, 43 percent of dual eligible beneficiaries were under age 65 and disabled compared with percent of the non dual eligible population. In addition, dual eligibles may choose a type of ma plan called a dual eligible special needs plan dsnp, which is designed to target the needs of this population. They are often in poor health and among the most costly patients to both programs. Mar 18, 20 mltc mandatory target population the 2011 budget legislation requires that all dual eligible medicaid and medicare who are. On february 22, 20, the illinois department of healthcare and family services hfs received approval from the federal centers for medicare and medicaid services cms to jointly implement the medicaremedicaid alignment initiative mmai. Enrollment of eligible individuals in the rest of nys will begin in july 2016.
Pdf improved care coordination for dual eligibles has the potential to reduce hospitalizations and eliminate duplicative services. As long as you meet the federal qualifications for medicare eligibility and the statespecific qualifications for medicaid eligibility, you will qualify as a dual eligible. State allows duals to be enrolled in both a medicare dsnp and medicaid managed care plan administered by anthem amerigroup, so dual may be enrolled in both plans separately. Oct 21, 2016 dual eligibles are among the most vulnerable of our fellow citizens and historically among the highest utilizers of healthcare services, says roth. Age 21 and older and in need of communitybased long term care services for more than 120 days must enroll in a managed long term care plan or other care coordination model. Dual eligible special needs plans dsnp a guide for agents. Approximately 11 million americans are dual eligible, representing 20% of the medicare population. Mental health and substance use disorders are defined based on the. The term includes beneficiaries enrolled in medicare part a andor part b and getting full medicaid benefits andor assistance with medicare premiums or cost sharing through the medicare savings program msp.
Dual eligible beneficiaries are more likely than non dual eligible beneficiaries to be under age 65 and disabled. The state mma file definition of medicaremedicaid enrollee implies concomitant enrollment in any given month in medicaid and medicare part a andor part b. The project, also known as the demonstration, is testing an innovative payment and service delivery model to improve coordination of services for dual eligibles, enhance quality of care, and reduce costs for both the. People eligible for both medicare and medicaid benefitsknown as dualeligible beneficiariesare a varied group, but many have extensive health care needs and account for a disproportionate share of spending on medicare and medicaid. Dualeligible beneficiaries of medicare and medicaid. Target populations must be specifically defined, as the definition determines whether sampled cases are eligible or ineligible for the survey. For more information, refer to the ssa program operations manual system hi 00801. List and definition of dual eligibles medicaremedicaid enrollees. Defining medicaremedicaid enrollees in cms data sources.
List and definition of dual eligibles medicaremedicaid. Care management practices in integrated care models for dual. Dually eligible beneficiaries nder medicare and medicaid mln ooklet. To qualify for medicare, individuals generally need to be 65 or older, have a qualifying disability, or be diagnosed with endstage renal disease. The term medicaremedicaid enrollee is synonymous with the term dual eligible beneficiary which has been used in prior reports by cms and other organizations. For people who are eligible for both medicare and medicaid benefits, known as dual eligibles, medicare and medicaid coverage are largely complementary. They make up 18 percent of the medicaid population but represent 46 percent of medicaid expenditures. In some instances, the target population is restricted to exclude. Medicaid program medicaid is a health insurance program funded by federal and state governments that pays costs for. For medicaid benefits, beneficiaries generally enroll in their states medicaid ffs program or a medicaid managed care plan administered by an mco under contract with the state. Definitions of various terms used in this report appear in the glossary at the end of the report. The dualeligible population can be divided into full duals and partial duals on the basis of the medicaid benefits that people are eligible to receive. The dual eligible population is far from homogeneous. Transition of dual and nondual eligible lthhcp participants.
An analysis of selected mental health conditions among maryland fullbenefit dualeligible beneficiaries overview at the request of the maryland department of health and mental hygiene dhmh, the hilltop institute conducted a series of analyses on the health care utilization of marylands fullbenefit dualeligible beneficiaries. Dual eligible project mmp the goal of the project is to better coordinate the care those dual eligible members receive. About 9 million people in the united states are covered by both medicare and medicaid, including lowincome seniors and younger people with disabilities. Ninetyfour percent of members are dually eligible for medicare and medicaid and the remaining 6 percent of members are eligible for medicaid only. If camffs dual eligibles had the same readmission and hospitalization rate. Jan 31, 2017 health plan php programthe program for nondual eligible beneficiaries before launching the capitated program for dualeligible beneficiaries. Less than 30% of those dual eligibles are enrolled in a medicare advantage or special needs plan dsnp. Cmss financial alignment demonstration and the medicare savings programs have income that exceeds the ssi eligibility limit but is below the federal poverty level.
Medicare and medicaid benefits and spending for dualeligible beneficiaries through. Total dually eligible beneficiary population continues to grow. Model of care moc specific goals and objectives for the snp population including conducting the. This page highlights some key resources examining the dual eligible population and provides you with the standard search result page for a sitewide search on the dual eligible tag. Cms, dual eligible categories and list and definition of dual eligibles, 23. Glossary of terms related to dualeligible beneficiaries. Unfortunately, dual eligible beneficiaries are often poorer in health and require more expensive treatment options. People dually eligible for medicare and medicaid fact. The geographic and temporal characteristics of the target population need to be delineated, as well as types of units being included. Dual eligible beneficiaries are a varied group, but many have extensive health care needs, stemming from multiple illnesses and disabilities. The full dual subgroup increased by 6% during the 20052010 timeframe.
These patterns fit with our expectations that for most indicators the hcbs qi denominator population would experience higher rates of the qi events than the medicaid population overall, and likewise that the hcbs dual eligible subpopulation. Dualeligible beneficiaries are those who qualify for both medicare and medicaid. Additional billing requirements for dually eligible beneficiaries. Defining medicaremedicaid enrollees1 in cms data sources a. Any state that we can have dual citizens on our dsnp and separate agpanthem medicaid note. Apr 19, 2016 individuals identified as harp eligible must be offered care management through statedesignated health homes. Dual eligibles on the rise the dualeligible population is large and growing rapidly currently, there are more than 9. Dual eligibles are a diverse population in terms of need forand use of medical and nonmedical services, but as a group they are poorer and sicker than medicare and medicaid beneficiaries who are not dually eligible.
Dual eligible project mmp texas health and human services. Approximately 12 million americans are dual eligible, representing 20% of the medicare population. Models that improve health and quality of life for people eligible for both medicaid and medicare dual eligibles are also of great importance to the adadrd population, as approximately 19% of the dual eligible population has some form of dementia. In medicare, they comprise 16 percent of the population but account for 27 percent of all expenditures. Learn the ins and outs of the dual eligible special needs plan today. Illinois department of healthcare and family services managed. Dual eligibles, chronic conditions, and functional impairment. Dual eligible beneficiaries receive both medicare and medicaid benefits by virtue of their age or disability and low incomes.
Quality of care is also an important concern in the care of the dual eligible population. A total of 23 states and the district of columbia use this eligibility pathway, which accounts for about 15 percent of full. Statistics and quality cbhsq, samhsa, and by rti international in research. Over our 40 year history, scan has worked to build the programs and expertise required to support the dually eligible and actively promote a thoughtful public policy discussion to how to. Dual eligible population duals in medicaid transformation a guide to how the dual experience is captured what is a dual or dual eligible person. Harp enrollment of eligible individuals began in new york city in october 2015, and an estimated 45,000 individuals will be enrolled in nyc harps as of 2016.
In the case of full duals, for example, half initially qualified for medicare because of disability rather than age, and nearly onefifth have three. Dual eligible population analysis for scan health plan national. Dual eligibles are individuals who are entitled to medicare part a andor part b and are eligible for some form of medicaid benefit. In our everchanging medicare market, we have an emerging demographic that is significantly underrepresented dual eligibles. Dualeligible beneficiaries vary, however, in the amount of medicaid benefits for which they qualify. Dual eligible population duals in medicaid transformation. Will dhcs revise apl 18020 to allow dual eligibles in this population to be eligible for the sb 1004apl 18020 benefit. While minimum federal income and asset limits are specified, as is true for other medicaid categories of eligibility, states are permitted to make the eligibility criteria more generous. Overall, the nations dual eligible population increased 20% from 20052010, spurred by a doubling of the partial dual subgroup. Dual eligibles and the value of medicare advantage ahip. Dual eligible special needs plans dsnps model of care.
Special needs plans and the coordination of benefits and. Medicare and medicaid benefits and spending for dualeligible beneficiaries through contracts with. Report to the joint legislative oversight committee on. Trends in dualeligible population composition, spending, and service use. Work is underway at a number of agencies to identify models that provide more effective and efficient care for people with adadrd. The dual eligible population is diverse, and includes many beneficiaries with multiple chronic illnesses, dementia and other forms of cognitive impairment, physical. An analysis of selected mental health conditions among.
Development of quality indicators for the home and community. These patients account for 16% and 15% of medicare and medicaid beneficiaries respectively, but make up 27% and 39% of costs. C behavioral health statistics and quality the cbhsq report. The health and cost challenges of the dualeligible population are further complicated by the variation in coverage and payment policies offered by 50 separate and unique medicaid policies. Dual eligibles are lowincome individuals who are eligible for both medicare and medicaid bene.
This population is diverse and includes individuals with multiple chronic conditions, physical disabilities, and cognitive. The term dual or dual eligible refers to people who qualify for both medicaid and medicare. Number of heart disease deaths per 100,000 population by gender march 3, 2020. The mmai is a groundbreaking joint effort to reform the way care is delivered to clients eligible for. All dual eligible beneficiaries are low income, but those in dsnps tended to have somewhat different demographic characteristics relative to those dual eligible beneficiaries in other ma plans. Managed care plans for dualeligible beneficiaries medpac. This transition will allow time for the department, beneficiaries, health plans and providers to adjust to the capitated delivery system prior to expanding to fulldual eligible beneficiaries. Scan health plan president to discuss serving the dual. Dually eligible beneficiaries dually eligible beneficiaries generally describes beneficiaries enrolled in medicare and medicaid. Why arent duals counted in attribution for project incentive allocation, and pay for. Medicare is the primary payer for doctors, hospitals, posthospitalization skilled nursing, home health care and prescription drug costs. Dually eligible individuals must navigate two separate programs.