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By Athena Mandros

The shifting trends in the “dual eligible” population are important to the strategy of any health and human service organization that serves consumers with complex needs. Why? Dual eligibles are more likely to report functional impairments—30% of dual eligibles versus 9% of the Medicare population. And they are more likely to have a serious mental illness—30% of full benefit dual eligibles and 25% of partial benefit dual eligible, compared to 11% of the Medicare-only population (see Trends In Behavioral Health: A Reference Guide On The U.S. Behavioral Health Financing & Delivery System).

This translates to higher costs as well. In 2013 (the latest year data is available), dual eligibles accounted for about 20% of the Medicare population, but represented 34% of spending. In Medicaid, they represented about 15% of the population, but accounted for 32% of spending. The average cost of care for a dual eligible (both Medicaid and Medicare) is $29,238 compared to $8,593 for a Medicare-only beneficiary (see Managed Care Plans For Dual-Eligible Beneficiaries).

Our new analysis of this market, just published in our new report, Medicare-Medicaid Dual Eligible 2018 Market Update: Enrollment & Coverage, turned up two trends that I think are important to every organizations planning to serve these consumers. The first is the proportion of the Medicaid and Medicare population that is “dually eligible” varies greatly by state, affecting the total market. The other is the sizable increase in managed care enrollment.

State variability in the size and proportion of the dual eligible is pronounced. The absolute number of dual eligible individuals varies by the size of the state population—California has the largest dual eligible population at 1.45 million, and Wyoming has the smallest at 10,473. Additionally, Nevada had the greatest increase in their dual eligible population between 2015 and 2017, growing about 27%. Vermont’s dual eligible population decreased about 2.8% during the same time period. And, equally important for strategy is that fact that the proportion of the Medicare and Medicaid enrollees that are dual eligible varies widely by state. For example, in Maine, dual eligibles represent 33% of the Medicaid population, while they represent only 8% of the Medicaid population in Colorado. The states with the highest percentage of their Medicare population as dual eligibles include the District of Columbia at 42%, and Connecticut, Maine, and Mississippi at 29%. Utah and Wyoming report the lowest percentage at 11%.

In addition to state variability in the number and proportion, states have very different policies about managed care for the dual eligible population. As of last year, an estimated 33% of all dual eligibles were enrolled in Medicare managed care, and 40% of full-benefit dual eligibles were enrolled in Medicaid managed care. This is an increase from 2011, when 22% of the dual eligible Medicare population was enrolled in some type of managed care, and 24% of dual eligibles were enrolled in Medicaid managed care. Dual eligibles are enrolled in only fee-for-service (FFS) systems in 12 states; dual eligibles are enrolled in only managed care systems in three states; and dual eligibles have a choice to enroll in one or more financing systems in 36 states.

Case in point, both Virginia and Pennsylvania are implementing new managed long-term services and supports (MLTSS) programs and a primary objective of the programs is to provide managed care for dual eligibles whether or not they are in need of LTSS (see What Is Community HealthChoices? and Virginia Medicaid Launches Mandatory MLTSS Enrollment; Specialty Behavioral Health Services Included). Additionally, Idaho is developing mandatory Medicaid managed care plans for dual eligible populations, despite the fact that the state does not have managed care for any other Medicaid population (see Idaho Medicaid Plus Overview & Public Comment).

The strategy implications? A large portion of Medicaid and Medicare spending is in play with new opportunities for health plans, care coordination organizations, and provider organizations. The catch? The opportunities vary by type and by size depending on the state.

For more on dual eligible enrollment, proportion of Medicaid plans, and managed care policy by state, check out our new analysis in the report, Medicare-Medicaid Dual Eligible 2018 Market Update: Enrollment & Coverage. Other recent relevant strategy resources in the OPEN MINDS Industry Library, check out Health Homes, Specialty Health Plans, CCBHCs. Oh My!, The 2018 Update On State Medicaid Care Coordination Initiatives: An OPEN MINDS Reference Guide, and Florida Medicaid Awards Contracts; Wellcare Wins SMI Specialty Plan Contracts.

For even more, join us at The 2018 OPEN MINDS Management Best Practices Institute in Long Beach, California on August 15 for the session, “Can There Be Best Practices In Complex Care? A Town Hall Discussion”, featuring Stacy DiStefano, Chief Operating Officer, OPEN MINDS; Clayton Chau, M.D., Ph.D., Regional Executive Medical Director, St Joseph Hoag Health/Providence St Joseph Health Southern California Region; and Mario San Bartolomé, M.D., M.B.A., M.R.O., FASAM, National Medical Director, Substance Use Disorders, Molina Healthcare.

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