Medicare is the federally administered health insurance program for people age 65 and older. Medicaid is also a federally funded program, although its focus is to provide health care to low-income Americans, such as families, children, and people with disabilities.
It is possible for a person to be enrolled in both of these, and those beneficiaries are called “dual eligibles.” Recent federal statistics suggest that dual eligibles comprise 15% of all Medicaid enrollees, but account for nearly 40% of all costs. Dual eligibles represent 20% of all Medicare beneficiaries, with more than 30% of all costs. In 2009, that’s over $250 billion spent on this group.
Massachusetts and One Care
Many states have tried to roll Medicaid and Medicare into one, all-encompassing program for the dual eligible population. Massachusetts, for example, had something called the Senior Care Options program, which allowed its dual eligible population to receive coverage from both programs under one umbrella.
Recently, Massachusetts became the first state to utilize a piece of the Affordable Care Act (ACA) that will allow dual eligible beneficiaries even better care and at a lower cost. It’s called the One Care program, and it’s the combination of Medicare and Medicaid coverage that gives beneficiaries a case manager who will oversee their treatment and billing, while providing them with all-encompassing health coverage. One Care beneficiaries are issued a card that signifies their participation in this program, and they present it at all of their doctor or physician appointments.
Other states are looking at what Massachusetts has done and considering how the combination of Medicare and Medicaid will work for them. Under the ACA, the combination of both programs allows state Medicaid and the federal Medicare agency to split potential cost savings. A few states, such as Colorado, Connecticut, Iowa, Missouri, North Carolina, and Oklahoma are planning to integrate Medicare and Medicaid on their own, without the ACA legislation.
Not every state
For many states, merging these programs is easier said than done. Some experts assess that if Medicare and Medicaid are combined hastily, there’s a real risk of hurting dual eligibles in the long run.
“The layers of complexity are mindboggling,” said Kevin Prindiville, executive director of the National Senior Citizens Law Center. “It needs to be done in a way that includes a lot of thought and a lot of planning about what a better system looks like.”
California is feeling this integration pressure as it currently attempts to combine Medicare and Medicaid for 456,000 people—six times the amount of dual eligibles in Massachusetts. Even if California-based dual eligibles opt out of an integrated plan, their Medicaid coverage will be co-opted by a managed care company regardless, and their network of doctors and coverage details are subject to change as well. Variations in existing enrollment deadlines and effective dates have succeeded only in exacerbating an already confusing situation for many.
The challenge currently faced by California is intrinsic of the issues facing all states looking to combine Medicare and Medicaid for dual eligibles. While private care organizations of both the non-profit and for-profit kind concede that this type of integration will be challenging, many support the strategy, regardless.
USA Today also covered this story.
Should Medicare and Medicaid coverage be combined for dual eligibles?
Medicare has neither reviewed nor endorsed this information.