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The various Medicare coverage options for dual-eligible individuals are summarized below and in Appendix Table 1.
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“Partial-benefit” dual-eligible individuals are not eligible for full Medicaid benefits but are eligible for assistance with Medicare premiums and, in many cases, cost sharing, also through the Medicare Savings Programs. Medicaid also provides most full-benefit dual-eligible individuals premium and in many cases, cost-sharing assistance through the Medicare Savings Program. Most (73%) dual-eligible individuals are eligible for the full range of Medicaid benefits not otherwise covered by Medicare and are referred to as “full-benefit” dual-eligible individuals. State Medicaid programs cover benefits that Medicare does not cover, such as long-term services and supports and non-emergency transportation, as well as a broader set of behavioral health services through Medicaid fee-for-service or Medicaid managed care. This decision may have implications for how dual-eligible individuals receive their Medicaid benefits and the degree to which that coverage is coordinated with Medicare. Like all Medicare beneficiaries, dual-eligible individuals may choose to receive their Medicare benefits through traditional Medicare or a Medicare Advantage plan.
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Three in 10 (30%) dual-eligible individuals were enrolled in a dual-eligible plan, most of whom (24%) were in coordination-only dual eligible special needs plans (D-SNPs).Just over half (51%) of dual-eligible individuals received their Medicare benefits through traditional Medicare in 2020, while the remaining 49% were enrolled in Medicare Advantage plans (Figure 1).To inform consideration of these coverage and financing options, including what they might mean for how dual-eligible individuals get their Medicare and Medicaid benefits, and who would be most affected, this brief presents national and state-level sources of Medicare coverage for dual-eligible individuals, by demographic characteristics, based on the 2020 Medicare Beneficiary Summary File (See Methods for details and Appendix Table 1). In response to these concerns, federal and state lawmakers have been working to develop, test and implement a variety of coverage and financing options to improve coordination of care for this population.
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At the same time, there are ongoing concerns about a lack of integration of services across the two programs that may contribute to fragmentation of care, poor outcomes, and high costs. Together, Medicare and Medicaid cover a range of services and financial supports to help meet the diverse needs of the dual-eligible population, which is more racially and ethnically diverse, and more likely to be in poor health than Medicare beneficiaries without Medicaid. Under the broad umbrella of Medicare coverage, dual-eligible individuals can be covered under a variety of different arrangements, including traditional Medicare, Medicare Advantage plans that are available to all Medicare beneficiaries, and plans that are designed specifically for this population (referred to here as “dual-eligible plans”). Medicare and Medicaid provide health coverage to 12.5 million individuals who are enrolled in both programs, known as “dual-eligible individuals.” Medicare is their primary source of health insurance coverage, and Medicaid, jointly funded by federal and state governments, provides supplemental coverage.