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Look-Alikes Cause Confusion
Despite the potential benefits of integrating care for dually eligible beneficiaries, about 70% of duals receive care through nonintegrated plans.Recent research indicates that some duals are increasingly enrolling in nonintegrated “look-alike” plans with disproportionate impacts on vulnerable communities across the country. The benefits and cost-sharing of the look-alike plans are similar to those of integrated dual eligible special needs plans, but the look-alikes may not meet federal and state standards for integrating care.
Between 2013 and 2020, duals’ enrollment in look-alike plans increased nearly elevenfold, from about 20,900 duals across four states to 220,860 duals across 17 states. According to researchers, 30% of dually eligible beneficiaries who enrolled in these nonintegrated look-alike plans were previously enrolled in integrated plans and more likely to be older, Hispanic and from socially vulnerable communities.
[EXTERNAL LINK] - Those Eligible for Medicare and Medicaid Face Twin Challenge
More than 12.2 million low-income Americans receive coverage under both Medicaid and Medicare due to age or disability.
These “dually eligible beneficiaries,” or “duals,” account for a disproportionate share of spending in both of the health care insurance programs, often because of multiple chronic conditions, disabilities and complex needs, including social support needs.
Recent research on the health-related social needs of dually eligible people, such as food insecurity, housing instability or transportation issues, shows how these needs may be linked to health outcomes. Financial limitations and food insecurity, unreliable transportation, loneliness or social isolation, and housing insecurity were associated with higher rates of hospitalizations and emergency department visits. For example, unreliable transportation was associated with 85% more hospitalizations and 68% more emergency department visits among duals.
Medicare and Medicaid are separate programs that maintain independent rules on eligibility and benefits. Because the programs are not designed to work together, duals may experience fragmented or uncoordinated care. For example, dually eligible beneficiaries report difficulty in getting and maintaining eligibility for both programs, confusion about coverage options and available benefits, and the need for help in navigating the programs, among other challenges.
