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Proposed Medicaid Rules Should Focus On Dual-Eligible Population

In a letter to CMS, Arnold Ventures calls for better integration with Medicare to improve delivery of home and community care.

The United States’ population is aging rapidly. More than 1 in 6 people are over the age of 65 today, and more than 10,000 additional people turn 65 every day. By 2034, for the first time in U.S. history there will be more people over the age of 65 than under the age of 18

These demographic trends mean growing demand for health-related services and programs that will allow Americans to stay in their communities and live in their homes as they age. 

However, providing those services and programs remains a challenge – especially for Americans who are dual-eligible and qualify for both Medicare and Medicaid. 

Fortunately, the federal government is working to tackle this problem. The Centers for Medicare and Medicaid (CMS) recently released two proposed rules (1, 2) that, if finalized, would make sweeping reforms to the delivery of these services paid for by Medicaid. 

These new rules make some important strides to ensure that the home and community-based services covered by Medicaid are coordinated with Medicare coverage for those enrolled in both programs. But more must be done. 

In letters sent to CMS on June 27, AV elevated the experience of the dual-eligible population, encouraging the agency to consider opportunities to center this group and their unique set of needs.

People aren’t disjointed, it’s our systems that are disjointed,” said Arielle Mir, Vice President of Complex Care at Arnold Ventures. Efforts to improve home and community-based services funded through Medicaid must contemplate the needs of people who are dual-eligible and their Medicare coverage.” 

The Benefits of Home and Community Care

While institutions like nursing homes can provide around-the-clock support for aging Americans, most people report preferring to receive long-term care services in their homes or the community. 

There are significant benefits of having home and community-based services and supports available to people where they live. For one, it’s often less expensive to deliver care in the community than in a nursing home. Additionally, these types of supports can prevent hospitalizations due to issues like falls, which may occur when people who would benefit from help at home try to care for themselves independently. 

The benefits of these services aren’t limited to older Americans. People living with disabilities – including physical, developmental, and intellectual disabilities – oftentimes also rely on these services to remain achieve their health goals. 

Integrating Medicaid and Medicare

Medicaid is the primary financer of these home and community health-related services nationwide, spending more than 475 billion dollars a year and paying for almost 50% of these services. 

Attempting to improve access to these services – such as with CMS’ two new proposed rules – will help provide what people want, can lead to better outcomes, and can save the government money. But if long-term care services are not coordinated with other health care services, such as primary care doctors, then individuals may fall through the cracks and not receive the support they need to lead healthy lives in their communities. 

This unfortunate reality is all too common for the 9 million dual-eligible individuals who are enrolled in both Medicaid and Medicare simultaneously. 

Their Medicaid coverage provides them with long-term care services, including supports in the home and community, while Medicare functions as more traditional health insurance and pays for hospitalizations and primary care visits. 

The comment letter from AV recommends that CMS address the full range of coverage for the dual-eligible population, and issue guidance outlining how the pieces — including Medicare and Medicaid — fit together for this group. 

Read the entire comment letter below: