Transcript Figure 1 Dual Eligibles: The Basics Barbara Lyons, Ph.D. Director, Kaiser Commission on Medicaid and the Uninsured Senior Vice President, Henry J.

Figure 1
Dual Eligibles: The Basics
Barbara Lyons, Ph.D.
Director, Kaiser Commission on Medicaid and the Uninsured
Senior Vice President, Henry J. Kaiser Family Foundation
For
Alliance for Health Reform
Washington, DC
June 3, 2011
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 2
9 Million Dual Eligibles are Covered by Both
Medicare and Medicaid
Medicare Dual
Eligibles
34 Million 9 Million
Total Medicare Beneficiaries, 2007:
43 million
Medicaid
49 Million
Total Medicaid Beneficiaries, 2007:
58 million
Source: Kaiser Family Foundation analysis of Medicare Current Beneficiary
Survey, 2007, and Urban Institute estimates based on data from the 2007 MSIS
and CMS Form 64.
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 3
Medicaid Supplements Medicare for
Dual Eligibles
• Nine million Medicare beneficiaries, including 5.5 million seniors
and 3.4 million disabled, receive help from Medicaid
• Medicare is a national program that provides coverage of
medical services, including hospital, physician, prescription
drugs, and limited post-acute care, but requires premium
payments and cost-sharing (ie, hospital deductible $1,132
annually; Part B premium $115/month in 2011)
• Medicaid is a joint federal-state program that supplements
Medicare for low-income beneficiaries
– Provides financial assistance with Medicare premiums and
deductibles and co-insurance for Medicare-covered services
– Medicaid helps pay for services not covered by Medicare,
such as hearing, vision and long-term care
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 4
How Do Dual Eligibles Qualify for
Medicaid?
•
For the poor: States are generally required to cover individuals
qualifying for SSI (income below 75% of poverty and $2,000 or less in
assets for an individual); states have the option to cover individuals up
to 100% of poverty
•
For those with high medical or long-term care expenses, special
eligibility and level of need rules apply
- 38 states allow individuals who need nursing home care to qualify
up to 300% of the SSI level ($2,022 per month for an individual),
but require them to contribute most of their income to the cost;
- 26 states have a medically needy program enabling individuals to
spend-down;
- Eligibility for home and community-based care is typically linked to
nursing home standards
•
Most dual eligibles qualify for full Medicaid benefits, while some qualify
for more limited Medicaid assistance to help with Medicare premiums
and cost sharing through Medicare Savings Programs
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 5
Dual Eligibles are Poorer and Sicker than Other
Medicare Beneficiaries, 2008
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008 Access to Care File.
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 6
Dual Eligibles Use More Medicare
Services Than Other Medicare
Beneficiaries, 2006
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary
Survey Cost & Use File 2006.
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 7
Medicare Spending is Higher for Dual Eligibles
Living in LTC Facilities Than for Duals Living in the
Community, 2006
Share of Dual
Eligibles
16%
84%
NOTE: Excludes Medicare Advantage enrollees’ spending. Excludes Medicare prescription drug spending. Includes
beneficiaries who were in long-term care facilities as of January 1, 2006, including those who died before the end of 2006.
SOURCE: Medicare spending and enrollment estimates from Kaiser Family Foundation analysis of the CMS Medicare
K
Current Beneficiary Survey Cost and Use File, 2006;
A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 8
Dual Eligibles Account for Disproportionate Share of
Spending in Medicare and Medicaid
Medicare FFS
Medicare FFS
Enrollment, 2006 Total: Spending, 2006 Total:
36 million
$299 billion
Medicaid Enrollment,
2007 Total:
58 million
SOURCE: Medicare spending and enrollment estimates from Kaiser Family Foundation analysis of the CMS Medicare
Current Beneficiary Survey Cost and Use File, 2006;
Medicaid spending and enrollment estimates from Urban Institute analysis of data from MSIS and CMS Form 64,
prepared for the Kaiser Commission on Medicaid and the Uninsured, 2010.
Medicaid Spending,
2007 Total:
$311 billion
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 9
Expenditures for Dual Eligibles as a Share of
Total Medicaid Spending, 2007
NH
VT
WA
MT
ND
MN
OR
ID
WI
RI
MI
WY
PA
IA
NE
NV
ILIL
CA
CO
MO
WV
DE
KY
NC
TN
OK
AZ
NM
MD
DC
SC
AR
MS
TX
CT
NJ
OH
IN
VA
KS
MA
NY
SD
UT
ME
AL
GA
LA
AK
FL
HI
US Average = 39%
NOTE: For 2007, the data quality for the state of AZ is not adequate to construct measures
of complete spending in the state.
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates
based on data from MSIS 2007.
25-34% (13 states including DC)
35-42% (18 states)
43% or more (19 states)
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 10
Medicaid Expenditures for Dual Eligibles,
FY 2007
Medicare Premiums
and Co-insurance,
$11 billion,
9.2%
Long-Term
Care,
$84,5 billion
70.1%
Home and
CommunityBased Services
$28.3 billion
25.5%
Medicare-Covered Services,
$18 billion,
14.9%
Other Acute,
$5.6 billion
4.7%
Institutional Care,
$56.2 billion,
46.6%
Prescribed Drugs,
$1.4 billion,
1.1%
Total Spending = $ 120.5 billion
Source: Urban Institute estimates based on data from MSIS and CMS Form 64,
prepared for the Kaiser Commission on Medicaid and the Uninsured, 2010.
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 11
Home and Community Based Services as a Share of
Total Medicaid LTC Spending on Elderly Duals, 2007
NH
VT
WA
MT
ND
MN
OR
ID
WI
RI
MI
WY
PA
IA
NE
NV
ILIL
CA
CO
MO
WV
DE
KY
NC
TN
OK
AZ
NM
MD
DC
SC
AR
MS
TX
CT
NJ
OH
IN
VA
KS
MA
NY
SD
UT
ME
AL
GA
LA
AK
FL
HI
5-10% (13 states)
US Average = 23%
NOTE: For 2007, the data quality for the state of AZ is not adequate to construct measures
of complete spending in the state.
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates
based on data from MSIS 2007.
11-18% (16 states)
11-24% (10 states)
25% or more (10 states including DC)
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured
Figure 12
Looking Ahead
•
Medicaid is an important adjunct to Medicare for many low-income
Medicare beneficiaries providing financial protections and a fuller
complement of medical and long-term care services.
•
Because of their poorer health status and greater health needs, dual
eligibles are an expensive population for both the Medicare and
Medicaid programs.
•
Fragmentation and lack of coordination between Medicare and
Medicaid can be challenging for dual eligibles, their families, and
providers and result in inefficient care.
•
Federal and state budget pressures could impact Medicare and
Medicaid’s role for dual eligibles.
•
The ACA provides new opportunities to coordinate care delivery for
dual eligibles through the Duals Office and Innovation Center and to
promote community-based care for dual eligibles, but requires assuring
beneficiary safeguards and accountability.
K A I S E R C O M M I S S I O N O N
Medicaid and the Uninsured