What Does the Term “Dual Eligible” Mean?
“Dual Eligible” is a term given to beneficiaries of both Medicare and Medicaid. In order to receive Medicare benefits, an individual must be at least 65 years of age or a recipient of Social Security Disability Insurance (SSDI) for at least 24 months.
Medicaid is the nation’s public health insurance program for people who are low-income. In fact, the program covers 1 in 5 low-income United States residents. It is a federal and state partnership administered by each state. This structure allows states to have the flexibility to determine covered populations, services, healthcare delivery models, and methods for paying physicians and hospitals. The goals of Medicaid are to cover a variety of health services while limiting enrollee out-of-pocket expenses.
Dual Eligibles Are At-Risk by Nature of Their Medicare Eligibility
Dual eligible beneficiaries are the most vulnerable in our community. There are two subsets to this population: the low-income elderly and low-income persons with disabilities. Both populations face an array of challenges to receipt of quality and timely healthcare.
Studies reveal that 60 percent of dual eligibles have multiple chronic physical conditions and 20 percent have more than one mental or cognitive condition. Almost 40 percent of dual eligibles have both physical and mental diseases or conditions compared to only 17 percent of all other Medicare beneficiaries. Comorbidity of physical and mental health conditions creates more complexity for care treatment programs.
Historically, comorbidities among dual eligibles—especially the chronic physical and mental/cognitive cases—made health service utilization high and care coordination across Medicare and Medicaid challenging. Half of the individuals with multiple mental or cognitive conditions and close to 2 out of 5 individuals with multiple physical conditions or both physical and mental/cognitive conditions accessed urgent and emergency care services 3 times more than a non-dual eligible. The Medicare Modernization Act in 2003 established Special Needs Plans (SNPs) to combine costs and ensure better care coordination to prevent costly and dangerous acute medical events for dual beneficiaries.
For individuals with disabilities, Medicaid eligibility is significantly more likely. Their disabilities can prevent them from securing a stable income. Medicare beneficiaries with disabilities may need services such as housekeeping, activities of daily living help, adult daycare, etc., which are expensive.
Dual Eligibles See Social Determinants of Health
A person’s environment significantly influences their health outcomes. Conditions in the places where people live, learn, work, and play affect a wide range of health risks and outcomes. These key factors are trending in the healthcare industry as Social Determinants of Health. Poverty, a widely recognized Social Determinant of Health, limits access to healthy foods, transportation, safe neighborhoods, and other contributors to overall wellbeing. As the umbrella Social Determinant of Health, it encompasses addressable barriers to achieve optimal health. A Medicare beneficiary experiencing poverty is at risk of not getting the care they need to live a healthy life. Even worse, poverty exposes this population to danger or harm.
Kasper, J., O’Malley, M., & Lyons, B. (2010, January 1). Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending. Retrieved from https://www.kff.org/health-reform/report/chronic-disease-and-co-morbidity-among-dual/
Bresnick, J. (2015, March 31). Higher Hospital Readmissions Worse Outcomes for Dual Eligibles. Retrieved February 6, 2020, from https://healthitanalytics.com/news/higher-hospital-readmissions-worse-outcomes-for-dual-eligibles