Dual Eligibles: The Basics

1. Dual Eligibles: The Basics Barbara Lyons, Ph.D. Director, Kaiser Commission on Medicaid and the Uninsured Senior Vice President, Henry J. Kaiser Family Foundation For Alliance for Health Reform Washington, DC June 3, 2011

2. 9 Million Dual Eligibles are Covered by Both Medicare and Medicaid Dual Eligibles 9 Million Total Medicare Beneficiaries, 2007: 43 million Total Medicaid Beneficiaries, 2007: 58 million Source: Kaiser Family Foundation analysis of Medicare Current Beneficiary Survey, 2007, and Urban Institute estimates based on data from the 2007 MSIS and CMS Form 64.

3. Medicaid Supplements Medicare for Dual Eligibles • Nine million Medicare beneficiaries, including 5.5 million seniors and 3.4 million disabled, receive help from Medicaid • Medicare is a national program that provides coverage of medical services, including hospital, physician, prescription drugs, and limited post-acute care, but requires premium payments and cost-sharing (ie, hospital deductible $1,132 annually; Part B premium $115/month in 2011) • Medicaid is a joint federal-state program that supplements Medicare for low-income beneficiaries • Provides financial assistance with Medicare premiums and deductibles and co-insurance for Medicare-covered services • Medicaid helps pay for services not covered by Medicare, such as hearing, vision and long-term care

4. How Do Dual Eligibles Qualify for Medicaid? • For the poor: States are generally required to cover individuals qualifying for SSI (income below 75% of poverty and $2,000 or less in assets for an individual); states have the option to cover individuals up to 100% of poverty • For those with high medical or long-term care expenses, special eligibility and level of need rules apply • 38 states allow individuals who need nursing home care to qualify up to 300% of the SSI level ($2,022 per month for an individual), but require them to contribute most of their income to the cost; • 26 states have a medically needy program enabling individuals to spend-down; • Eligibility for home and community-based care is typically linked to nursing home standards • Most dual eligibles qualify for full Medicaid benefits, while some qualify for more limited Medicaid assistance to help with Medicare premiums and cost sharing through Medicare Savings Programs

5. Dual Eligibles are Poorer and Sicker than Other Medicare Beneficiaries, 2008 SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008 Access to Care File.

6. Dual Eligibles Use More Medicare Services Than Other Medicare Beneficiaries, 2006 SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File 2006.

7. Medicare Spending is Higher for Dual Eligibles Living in LTC Facilities Than for Duals Living in the Community, 2006 Share of Dual Eligibles 16% 84% NOTE: Excludes Medicare Advantage enrollees’ spending. Excludes Medicare prescription drug spending. Includes beneficiaries who were in long-term care facilities as of January 1, 2006, including those who died before the end of 2006. SOURCE: Medicare spending and enrollment estimates from Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2006;

8. Dual Eligibles Account for Disproportionate Share of Spending in Medicare and Medicaid Medicare FFS Enrollment, 2006 Total:36 million Medicare FFS Spending, 2006 Total:$299 billion Medicaid Enrollment, 2007 Total:58 million Medicaid Spending, 2007 Total:$311 billion SOURCE: Medicare spending and enrollment estimates from Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2006; Medicaid spending and enrollment estimates from Urban Institute analysis of data from MSIS and CMS Form 64, prepared for the Kaiser Commission on Medicaid and the Uninsured, 2010.

9. Expenditures for Dual Eligibles as a Share of Total Medicaid Spending, 2007 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA OH NE IN NV WV DE IL IL UT VA MD CO MO CA KS KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI 25-34% (13 states including DC) 35-42% (18 states) US Average = 39% 43% or more (19 states) NOTE: For 2007, the data quality for the state of AZ is not adequate to construct measures of complete spending in the state. SOURCE:Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on data from MSIS 2007.

10. Medicaid Expenditures for Dual Eligibles, FY 2007 Medicare Premiums and Co-insurance, $11 billion, 9.2% Home and Community-Based Services $28.3 billion 25.5% Medicare-Covered Services, $18 billion, 14.9% Long-Term Care, $84,5 billion 70.1% Other Acute, $5.6 billion 4.7% Institutional Care, $56.2 billion, 46.6% Prescribed Drugs, $1.4 billion, 1.1% Total Spending = $ 120.5 billion Source: Urban Institute estimates based on data from MSIS and CMS Form 64, prepared for the Kaiser Commission on Medicaid and the Uninsured, 2010.

11. Home and Community Based Services as a Share of Total Medicaid LTC Spending on Elderly Duals, 2007 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV WV DE IL IL UT VA MD CO MO CA KS KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL HI 5-10% (13 states) 11-18% (16 states) 11-24% (10 states) US Average = 23% 25% or more (10 states including DC) NOTE: For 2007, the data quality for the state of AZ is not adequate to construct measures of complete spending in the state. SOURCE:Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on data from MSIS 2007.

12. Looking Ahead • Medicaid is an important adjunct to Medicare for many low-income Medicare beneficiaries providing financial protections and a fuller complement of medical and long-term care services. • Because of their poorer health status and greater health needs, dual eligibles are an expensive population for both the Medicare and Medicaid programs. • Fragmentation and lack of coordination between Medicare and Medicaid can be challenging for dual eligibles, their families, and providers and result in inefficient care. • Federal and state budget pressures could impact Medicare and Medicaid’s role for dual eligibles. • The ACA provides new opportunities to coordinate care delivery for dual eligibles through the Duals Office and Innovation Center and to promote community-based care for dual eligibles, but requires assuring beneficiary safeguards and accountability.