Health care can drastically improve a person’s quality of life — and yet navigating the health system can feel incredibly complex. This is especially true for those who are eligible for both Medicare and Medicaid, also known as dually eligible individuals.
Dual Special Needs Plans (DSNPs) coordinate care for dually eligible individuals and simplify care experiences. These plans offer flexibility through different plan benefit packages and can be tailored to an individual’s care needs. Let’s take a look at the ways members become eligible for DSNPs, and how these plans help individuals access their full benefits through both programs.
Medicare and Medicaid coverage, cost sharing and eligibility
The Medicare and Medicaid programs differ in several ways.
Medicaid is a state-federal partnership, meaning that it is administered by states and funded by both federal and state dollars. Because the program is driven by states, the benefits provided under Medicaid vary across the nation. On the other hand, Medicare is a federal program, making it fairly uniform from state to state in terms of who qualifies, and which benefits are available.
While dually eligible individuals represent about 20% of the Medicare population and 15% of the Medicaid population, they make up 34% and 33% of the programs' costs, respectively. When it comes to paying for DSNP services, Medicare always pays first, and Medicaid picks up the cost share or covers services as primary payer that Medicare may not cover.
Medicaid provides health care coverage for:
- Individuals whose household income is below or near the Federal Poverty Level
- Individuals who require Long-Term Services and Supports
Medicare provides health care coverage for:
- Individuals ages 65+
- Individuals under age 65 with a disability (regardless of income)
Individuals may qualify for both programs depending on:
- Age
- Disability status
- Income
Under both programs, individuals typically have the choice to receive care services through managed care or fee-or-service (FFS) arrangements; however, individuals who choose FFS may experience limited customer support and will not receive access to certain clinical programs or additional benefits. They may also have a more fragmented care experience, creating more stress for both the individual and their caregiver, poorer health outcomes, and the possibility of receiving incomplete care in settings that aren’t best suited to meet their needs.
The unique needs of dually eligible individuals
There are about 12 million dually eligible individuals across the country, spanning a broad range of ages and needs. Some are young adults with disabilities (including intellectual and development disabilities [I/DD]). Others have serious, long-term illnesses and no longer have the financial means to pay for their health care expenses. Individuals over the age of 65 with fixed incomes below the Medicaid eligibility threshold are also eligible for both programs.
Within the dually eligible population:1
41% have at least one mental health diagnosis
49% receive Long-Term Services and Supports
60% manage multiple chronic conditions
Because of the wide range of services that dually eligible individuals require, navigating the care system can feel confusing. This population typically experiences complex medical and social needs that require a highly coordinated set of services to manage their conditions. They often live with functional limitations, unmet behavioral and social health needs and literacy challenges, thereby increasing the difficulty of managing stress. Some dually eligible individuals also face housing insecurity and struggle to overcome food access concerns.
DSNPs improve care coordination through managed care
DSNPs are unique to managed care and offer enhanced benefits and a streamlined experience for individuals navigating both Medicare and Medicaid programs. 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, such as unlimited transportation, dental, vision and long-term care. It’s important to note that some DSNPs include these types of additional benefits.
What is perhaps most unique about DSNPs is that they are tailored to the dually eligible population's care needs and help track and manage the services that members receive. As a result, DSNP members have additional support accessing services and can better avoid duplicative care and costs.
While there are other models that support integrated care for those who are dually eligible, such as Medicare-Medicaid plans and the Program of All-Inclusive Care for the Elderly (PACE), DSNPs offer nearly all of the same programmatic advantages, but with significantly less administrative burden for the state. Through DSNPs, states can create new opportunities and strategies to improve health outcomes and experiences for their dually eligible population.
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