Individuals eligible for Medicare and Medicaid, also known as dual eligible, have unique and complex care needs. These individuals make up a small but medically complex population that must navigate an uncoordinated set of benefits, eligibility criteria, providers and cost-sharing requirements in order to receive care. 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.
Roughly 12 million individuals are dually eligible for Medicare and Medicaid in the United States today. Many of these individuals manage multiple chronic conditions, physical or developmental disabilities, functional and cognitive impairments, and substance use disorders. They also often experience negative social determinants of health (SDOH), including food insecurity, social isolation and housing insecurity. When left to figure out confusing program rules and coordinate care benefits on their own, it often leads to incomplete care in inappropriate settings and poorer health outcomes.
Dual Special Needs Plans provide nuanced care for a complex population
Medicare Advantage (MA) Dual Special Needs Plans (DSNPs) coordinate benefits coverage between Medicare and Medicaid, simplifying the care process for many dual eligible individuals. These plans offer more care coordination than a person receives with a Fee-for-Service (FFS) model.
For states that use these plans, the DSNP is the primary payer of medical services, though Medicaid may cover some out-of-pocket costs and benefits (e.g., dental, vision and long-term care). Some DSNPs include these types of additional benefits, including transportation services.
While DSNPs are offered through MA, they have unique attributes within the Medicare space, including:
- Network — Like all MA plans, DSNPs must have a defined service area. However, their network may also be built upon specialists for certain health issues like diabetes.
- Eligibility — Individuals must meet specific eligibility requirements for the DSNP. This may be determined based on their required level of care, income, Medicaid eligibility status.
- Benefits — Benefits are set up to address the special needs of the targeted population. That may mean facility-based services and benefits, supplemental benefits such as transportation and meal delivery, or other services that will meet the needs of the individual. With many DSNPs, members will receive services at little or no cost.
- Clinical — The DSNP must create, file and follow Model of Care for each contract.
Compared to Medicare-Medicaid Plans (MMP) and the Program of All-Inclusive Care for the Elderly (PACE), DSNPs offer flexibility through different plan benefit packages. This allows the plan to be customized for different levels of need. While MMPs are open only to full dual eligible individuals, DSNPs can be tailored to be most appropriate for individuals with varying levels of eligibility and need, from those who are partially dual eligible to those needing Long-Term Services and Supports (LTSS).
Integrating care is at the heart of serving dual eligible individuals
The Centers for Medicare & Medicaid Services (CMS) and Congress recently began allowing MA plans, including DSNPs, to provide limited LTSS and SDOH benefits, like transportation and meal delivery. This is extremely helpful, as we are seeing an increased uptake of the special supplemental benefits for the chronically ill (SSBCI) that are not required to be health-related, and more supplemental benefits that fit under the expanded definition of primarily health-related benefits for this population.
However, this also raises concerns. While plans are given additional flexibility to provide these new benefits, there isn’t an increase of available funds for supplemental benefits. This means plans will have to make difficult choices to allocate limited funds across new SDOH benefits and more traditional, heavily utilized benefits (e.g., dental).
Meeting community-based organizations where they are
Health plans that manage DSNPs work closely with community-based organizations (CBOs) to assess and identify dual eligible individuals who are at increased risk. From there, they develop strategies to adapt services to address members’ health and well-being. For many CBOs, this might be their first time working with a managed care entity. It’s critical that health plans take the time to build a relationship with each CBO, establish a process to track encounter data, and ensure that all parties are closing the loop on referrals.
Listening to CBOs is the fastest way to establish and streamline these processes. We have seen just how important CBOs are to delivering care and supporting dual eligible individuals during the COVID-19 pandemic. Many individuals who might have been comfortable going to the grocery store once a week were suddenly homebound and potentially unable to access food services. Some of the flexibilities introduced to care for this population during the pandemic could better help them going forward if adopted on a more permanent basis. This unique time in our nation gives us the opportunity to reconsider how to best serve these individuals by both adding and reconfiguring how we traditionally deliver care.
Helping dual eligible individuals access available benefits
We are committed to designing DSNPs that are beneficial to dual eligible individuals. This includes working with partners and adding supplemental benefits that build off of what Medicaid is already doing. By continually monitoring which benefits dual eligible individuals are using, and helping enroll those who are eligible, we can increase coordination between Medicare and Medicaid to improve health outcomes.
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