By skyforbes 
Today, more than 100 million Americans are covered by either Medicare or Medicaid. Among this group are nearly 11 million low-income seniors or disabled people who qualify for help from both programs.
Medicare pays for most services these Americans need including hospital visits, prescription drugs, physician care, and skilled nursing facility care. Under Medicaid, states cover benefits not offered by Medicare such as long-term nursing facility services and home health services. Patients receiving help from both programs are known as Medicare “dual-eligibles” or simply “duals.”
What are Dual Eligible Plans?
Dual eligible plans were created in 2012 as part of a pilot program aimed at better treatment for Medicare and Medicaid patients. In a program created by the ACA, 14 dual demonstrations in 13 states are conducting these pilot programs. The goal of these plans is to provide better coordinated care for patients and to get them the extra care they require while also containing costs. Currently, dual-eligibles comprise about 14% of Medicaid enrollment, yet incur about 36% of Medicaid costs.
Dual eligible plans are tasked with solving a difficult problem. They must provide care not only for the most vulnerable low-income populations, but also the most senior portion of that population. Plus, these individuals are often those in poorest health.
Who Qualifies for Dual Eligible Plans?
Individuals qualify for dual eligibility if they currently receive Medicare (Parts A and B) and full Medicaid benefits, and if Medicaid pays for all or part of their Medicare co-payments, co-insurance, and deductibles.
One example of a dual eligible individual is Dennis Heaphy, a Boston resident and quadriplegic who began receiving dual-eligbile health care coverage in 2014. As part of initiatives included in the Accountable Care Act, Heaphy, could remain in his community and get care at home. This was a substantial change from the expensive and disruptive cycle of frequent hospital visits and long-term stays at skilled nursing facilities. Due to his chronic condition and low-income status, Heaphy exemplifies the complexities involved with dual-eligible plans.
Why are Dual Eligible Plans Needed?
Studies reveal dual-eligible individuals experience more emergency room visits, hospitalizations, chronic diseases, and age-related mobility issues. This group is also more likely to take seven or more medications. Not surprisingly, care for those in dual eligible plans is expensive.
In fact, dual eligible beneficiaries make up only 13% of the population, yet account for 40% of total Medicaid spending and 27% of total Medicare spending according to research done by the Kaiser Family Foundation. In addition, Medicare and Medicaid coverage has been disjointed and uncoordinated, causing patients to be unnecessarily sent to emergency rooms too often, further driving up costs. Dual eligible plans were created to address these challenges.
It’s also one of the primary issues Healthify is addressing by providing the necessary care coordination to the most vulnerable populations.
Home Health Care versus the Emergency Room
The difference between keeping patients healthy at home instead of relying on sporadic emergency room visits is significant. For Heaphy, it meant his insurance provided flexible benefits to cover the purchase of a new bed, breathing machine, and bandages, as well as coverage for in-home visits, massages, and acupuncture to help improve his breathing.
But many patients need more than access to traditional health care services. Those in dual eligible plans represent a diverse patient population. In addition to being elderly, disabled, or poor, they also could be homeless or suffering from addiction. These complexities are why each patient requires unique, coordinated care, and why creating one-size-fits-all plans is nearly impossible.
To provide more efficient care, health plans are relying on a variety of community services. By connecting patients to community services such as food delivery, housing initiatives, and addiction services, health plans can address the social determinants of health, keep patients out of the hospital, and provide an integrated solution to coordinated care.
Dual Eligible Plans Showing Promise
According to a recent article in Modern Healthcare, “early reports show that beneficiaries feel their quality of care is improving and noted declines in inpatient admissions.” That’s good news. And the Centers for Medicare & Medicaid Services and other advocates for dual-eligible plans are hoping the states will continue the pilot project.
While this initiative continues to be tested, we must also adopt modern approaches including community-based care and specialized health management software. With more integrated health services and social support, health care costs can be contained while improving care for our most vulnerable citizens.
At Healthify, we will continue to focus on supporting coordinating services within dual eligible plans using our health management software. Doing so helps connect elderly Medicaid recipients with community resources and addresses social determinants of health and a range of socio-economic factors affecting low-income people.