Individuals dually eligible for Medicare and Medicaid (“duals”) represent a small but medically complex population, often with functional limitations and unmet behavioral health needs. In many instances, this population must navigate an uncoordinated set of benefits, eligibility criteria, providers, and cost-sharing requirements. This fragmentation can lead to stress for the individual and their caregivers, poorer health outcomes, and individuals receiving incomplete care in inappropriate settings.
While these individuals represent only 20% of the Medicare population and 15% of the Medicaid population, they make up 34% and 33% of each program’s costs, respectively. In 2012, Medicare spent $194 billion on this population and Medicaid spent $119 billion, with 41% of the Medicare dollars spent on outpatient care and 50% of the Medicaid dollars spent on institutional long-term services and supports.¹
Dual Special Needs Plans (DSNPs)
Aligning the Medicare and Medicaid programs continues to be a challenge for states and Centers for Medicare and Medicaid Services (CMS); however, a key tool that states can use to facilitate this alignment and contain costs is a Medicare Advantage Dual Eligible Special Needs Plan (DSNP). Tailored to the unique needs of duals, DSNPs provide an opportunity for managed care organizations to offer enhanced benefits and streamline the experiences of duals as they navigate through multiple, complex programs. Additionally, DSNPs provide states with flexibility to implement programs based on the degree of Medicaid integration desired and state priorities, as DSNPs can meet states “where they are” along the continuum of integration and assist states in reaching their integration goals.
States can leverage the unique plan of care provided through DSNP contracts to improve care management and provide a single source of care coordination, simplify program experiences of duals, improve provider-patient relationships, and reduce program costs. As of April 2017, nearly 2 million individuals were enrolled in DSNP products across 43 states and territories.
UnitedHealthcare currently serves over 900,000* dually eligible individuals through our DSNP and FIDE SNP** products. In 2019, we offer these specialized plans across 36 states and Washington, DC, and in 27 of these states we enroll more duals than any other organization. We pride ourselves on our high-touch care delivery models for this vulnerable population and focus on closing gaps in care, including leveraging face-to-face community health workers and community supports to address the socioeconomic needs of our members, as well as the development of an individualized care plan that is shared with a member’s interdisciplinary care team. This high-touch care extends to the home through our call team as well as a nurse practitioner House Calls program we provide to individuals identified as not accessing their primary care provider. Because of our in-depth experience serving both the Medicare and Medicaid populations, we are able to successfully coordinate care across the full spectrum of needs for our dual members, including acute, behavioral health, and long-term services and supports to meet functional needs.
UnitedHealthcare Community & State Medicaid offerings
¹Medicare Payment Advisory Commission and Medicaid and CHIP Payment and Access Commission. (2017). Joint Databook: Beneficiaries Dually Eligible For Medicare and Medicaid.
²CMS Medicare Advantage/Part D Contract and Enrollment Data, SNP Comprehensive Report. April 2017.
*This number is inclusive of enrollees in both UnitedHealthcare Community & State and Medicare & Retirement DSNP markets.
** FIDE SNP is a Fully Integrated Special Needs Plan.