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The Perils of Choosing a Plan to Cover Both Medicare and Medicaid

Greater information and transparency could help dual-eligible beneficiaries choose the health coverage option that best meets their needs.

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No one — not even health insurance experts — is immune to the bewildering task of choosing and navigating their health care coverage. Low-income older adults and people with disabilities who are eligible for both Medicare and Medicaid have it particularly rough. These individuals must navigate two insurance programs while living with higher-than-average rates of chronic conditions and complex social needs.

The Medicare and Medicaid programs don’t work particularly well together, resulting in care that is highly fragmented. Dual-eligible patients often see a variety of health care providers that can be covered by either Medicare or Medicaid. Personal care workers, for example, who are covered by Medicaid, tend to have an intimate understanding of their clients’ care needs, and yet they are neither expected nor supported to communicate with their clients’ Medicare providers about changes in patient symptoms or functionality. Because of this fragmentation, people who are dual-eligible experience worse health outcomes and higher costs compared to their peers.

One solution to this fragmentation is integrated Medicare-Medicaid models. These models coordinate care and make the two programs feel more like one for the beneficiary. CMS’ recent proposed Medicare Advantage rule takes important steps towards increasing integration between Medicare and Medicaid. However, many dual-eligible individuals are not enrolled in these models, either because they do not have one available in their area or because they opt for a non-integrated option. When dual-eligible individuals describe their plan decision-making process, they say that it is rife with confusion, and in some cases, distrust.

A recent request for information (RFI) we released on the experience of dual-eligible individuals enrolling in health care coverage produced similar findings: People are incredibly confused by their coverage options and wish they had better resources for information and counseling. In their feedback, RFI respondents challenged policymakers to think about the variety of ways that dual-eligible individuals might be able to receive clear, actionable information about their coverage options. To date, it has been left up to states and plans providing integrated coverage to educate dual-eligible beneficiaries about these options. 

In our recent comments to the Medicare Advantage proposed rule, we urged CMS to consider additional efforts to increase clarity and transparency around enrollment in integrated models. One potential effort is described here.

What if the responsibility for enrollment education was shared?

What if any time a dual-eligible individual picked a non-integrated coverage option they were provided information that explained that integrated models exist and the benefits of such models? Additionally, what if dual-eligible individuals were reminded that the coverage option they selected does not offer their Medicaid benefits (or vice versa)?

These disclaimers — that the beneficiary is not enrolled in an integrated model, despite the availability of such models, and that their Medicaid or Medicare coverage information must be accessed elsewhere — could be included in beneficiary-facing materials, including introductory materials, descriptions of coverage, provider directories, pharmacy directories, and Explanation of Benefits documents. These requirements could extend to Medicare fee-for-service, Medicare Advantage plans, and the Medicaid program, as applicable, to ensure that beneficiaries receive clear guidance on where to find information about both sets of benefits.

How could disclaimers help?

The intention of these disclaimers is to support dual-eligible individuals and their caregivers to understand their health coverage options, the type of coverage model they have selected, and where to access additional information, including about integrated models.

Disclaimers might also help address dual-eligible look-alike” plans. These are Medicare Advantage plans that target dual-eligible individuals yet offer no degree of integration, which confuses beneficiaries and, in some instances, draws them away from truly integrated coverage options. While CMS continues to crack down on the availability of look-alike plans, a disclaimer could provide an additional layer of protection.

The key to these disclosures is that they shift the education burden from the individual, where it sits today, to the entities providing the coverage. Rather than expecting people to gather and make sense of complex insurance information, disclosure requirements can help guide and parse this information for people. Disclosures would articulate the various coverage options available to dual-eligible individuals and inform those enrolled in non-integrated models about their access points for their different benefits.

While a seemingly simple solution, fulfilling these disclosure requests would require more information sharing than exists today. It would likely require CMS to collect information about Medicaid enrollment in real-time and share it with a broader array of Medicare Advantage plans. Likewise, it would likely require states to provide more information about enrollment and where dual-eligible individuals can learn about their coverage than what is currently required. Taking these steps, however, is a worthwhile endeavor and one that will result in a patient population that is better equipped to select coverage models that meet their needs, and hopefully increase enrollment into integrated care models. This approach is an option as CMS works to promote integration between Medicare and Medicaid, including by incorporating the changes outlined in their recent Medicare Advantage proposed rule.