How Does Use of Medicaid Wraparound Services by Dual-Eligible Individuals Vary by Service, State, and Enrollees’ Demographics?

In 2021, 12.9 million people gained well being protection via each the Medicare and Medicaid methods. For the ones “dual-eligible folks,” Medicare is the principle payer and covers scientific acute and post-acute care, together with professional nursing facility services and products and residential well being care. Medicaid wraps round Medicare protection through paying Medicare premiums and normally, price sharing. Maximum dual-eligible individuals (9.5 million other folks in 2021) also are eligible for Medicaid advantages that aren’t another way coated through Medicare, together with long-term services and products and helps (LTSS), vision, and dental care (referred to right here as Medicaid “wraparound services and products” for dual-eligible folks).

Twin-eligible folks generally tend to have low incomes, top charges of long-term disabilities, and a couple of persistent prerequisites. With out protection of wraparound services and products beneath Medicaid, some dual-eligible folks could be not able to procure services and products equivalent to eye assessments, remedy for cavities, assist bathing and shifting to steer clear of bedsores; or they are going to must make tricky alternatives between paying out-of-pocket for the ones kinds of services and products and paying for his or her groceries. However Medicaid protection of those services and products varies extensively throughout states, doubtlessly resulting in variation in get right of entry to and use amongst dual-eligible folks.

This factor temporary describes the percentage of dual-eligible folks with complete Medicaid advantages who use wraparound services and products, together with institutional LTSS, home- and community-based services and products (HCBS), imaginative and prescient services and products, dental care, and non-emergency scientific transportation (NEMT); and the way use of those services and products varies through state and make a selection demographic traits of enrollees. The research contains 7.2 million folks with no less than 10 months of complete Medicaid protection in 2019 Medicaid claims information from T-MSIS (see Methods). The research items information from 2019, which might be anticipated to be extra consultant of non-pandemic usage tendencies than information from 2020, the latest yr of knowledge to be had when the research used to be performed. Key takeaways come with:

• Simply over 6 in 10 (61%) of the 7.2 million dual-eligible folks with no less than 10 months of complete Medicaid protection (4.4 million other folks) use no less than one Medicaid wraparound provider.
• Round one-fourth of full-benefit dual-eligible folks use home- and community-based services and products (27%) or imaginative and prescient services and products (26%), whilst charges of use are decrease for dental care (20%), NEMT (16%), and institutional LTSS (12%). Over one-third of dual-eligible folks (37%) use some form of LTSS—both institutional care or HCBS.
• The share of full-benefit dual-eligible folks that use no less than one Medicaid wraparound provider in 2019 levels from 32% in Florida to 88% in Minnesota. That variation stems from variation in charges of use for all particular services and products incorporated within the research.
• Twin-eligible people who are Hispanic use Medicaid wraparound services and products at decrease charges than those that aren’t Hispanic (50% use a number of wraparound provider when put next with 61%-65% amongst different racial and ethnic teams).
• Twin-eligible people who are ages 65 and older have upper charges of use of institutional LTSS and imaginative and prescient services and products than those that are more youthful and qualify for protection in keeping with a incapacity (16% vs. 5%, and 28% vs. 24%).
• Variation in charges of Medicaid wraparound provider use might stem from variations in peoples’ well being standing, demographic traits, states’ protection of quite a lot of services and products, enrollees’ consciousness of Medicaid’s advantages, form of Medicare protection, and different components that impact other folks’s want for and get right of entry to to care.

What number of dual-eligible folks use Medicaid wraparound services and products and the way does using services and products range throughout provider sorts?

A few of the 7.2 million dual-eligible folks with no less than 10 months of complete Medicaid, kind of 61% (4.4 million) of dual-eligible folks with complete Medicaid advantages use no less than one Medicaid wraparound provider, however charges of use for person services and products are decrease (Determine 1). The wraparound services and products on this research come with services and products that states are required to hide and services and products that states might elect to hide. Required services and products come with nursing facility care (which is a part of institutional LTSS), domestic well being care (which is a part of HCBS), and NEMT. Non-compulsory services and products come with dental care, imaginative and prescient care, and all HCBS instead of domestic well being. Charges of use through dual-eligible folks for Medicaid wraparound services and products through form of provider are:

• 27% for HCBS (2 million dual-eligible folks),
• 26% for imaginative and prescient care (1.9 million),
• 20% for dental care (1.4 million),
• 16% for NEMT (1.2 million), and
• 12% for institutional LTSS (0.9 million) (Determine 1).

Charges of use for wraparound services and products amongst dual-eligible folks fluctuate from charges for Medicaid enrollees who’re eligible as a result of they’ve a incapacity or are ages 65 and older however don’t have Medicare. Such enrollees have a tendency to be more youthful than dual-eligible folks as a result of most of the people ages 65 and older do have Medicare. Consequently, they’ve decrease charges of use of institutional LTSS and HCBS, however moderately equivalent charges of use for different wraparound services and products (Appendix Determine 1).

For LTSS wraparound services and products, a bigger proportion of dual-eligible folks with complete Medicaid advantages use HCBS than institutional LTSS (Determine 1). LTSS are typically equipped both in institutional settings, equivalent to a nursing facility or an intermediate care facility for other folks with highbrow disabilities, or in home- and community-based settings. HCBS come with a large vary of advantages, equivalent to get right of entry to to private care, grownup day care, and senior facilities, which might be all not obligatory advantages, aside from for domestic well being care (which may be coated through Medicare). Inside Medicaid in 2020, extra Medicaid enrollees use HCBS than institutional LTSS and on this research, over two times as many dual-eligible folks use HCBS when put next with institutional LTSS (27% when put next with 12% respectively). In 2020, dual-eligible people who used any Medicaid wraparound LTSS accounted for nearly two-thirds of all individuals who used Medicaid LTSS that yr.

For non-LTSS wraparound services and products, charges of use had been easiest for imaginative and prescient care, adopted through dental care, and NEMT (Determine 1). For the needs of this research, imaginative and prescient care is outlined to exclude services and products which are coated through conventional Medicare equivalent to remedy for cataracts and glaucoma. Imaginative and prescient care contains eye assessments and eyewear (contacts or eyeglasses) and dental care contains oral assessments, regimen cleanings, and extra in depth services and products equivalent to fillings, extractions, and root canals (see Methods for extra main points). NEMT supplies the ones in want with help attending to and from non-emergency scientific appointments and covers a broad range of modes of transportation together with taxis, buses, trucks, and private automobiles. Wraparound imaginative and prescient and dental services and products are typically now not coated through conventional Medicare however are frequently coated through Medicare Benefit plans as supplemental advantages.

How does using wraparound services and products range throughout states?

The share of full-benefit dual-eligible folks the use of no less than one Medicaid wraparound provider levels from 32% in Florida to 88% in Minnesota (Determine 2). In Alabama, Arizona, Florida, Michigan, South Carolina, and Tennessee, fewer than part of dual-eligible folks use any Medicaid wraparound services and products. Amongst the ones states, Alabama and Florida have moderately low charges of use for all particular services and products. Greater than 8 in 10 use a number of wraparound services and products in Connecticut, Iowa, Kansas, Minnesota, North Dakota, and Oregon, with Minnesota having top charges of every of the services and products aside from institutional LTSS.

In 45 states, extra dual-eligible folks with complete advantages use HCBS than institutional LTSS, however there may be huge variation in charges of HCBS use throughout states (Determine 3). Upper charges of HCBS use stem from projects to take away what has been known as the “institutional bias” in Medicaid. The share of full-benefit dual-eligible people who use HCBS levels from lower than 10% in Arizona, Florida, and Louisiana to over 50% in Kansas, Minnesota, New Mexico, Oregon, and Wyoming. On the other hand, a few of the ones low charges of HCBS use might mirror states’ problem reporting HCBS provider use within the Medicaid claims information: For instance, a previous KFF analysis famous that HCBS customers had been most likely undercounted in Rhode Island because of lacking HCBS information. States with top charges of HCBS use amongst dual-eligible folks additionally generally tend to have top charges of HCBS use amongst different Medicaid enrollees (Appendix Determine 2).

The share of dual-eligible people who use institutional LTSS levels from fewer than 5% in Alaska and North Carolina to greater than 25% in Connecticut and North Dakota. Past states’ protection insurance policies, the age and well being standing of dual-eligible folks is a determinant for LTSS use: KFF analyses to find that total, Medicaid enrollees who use LTSS have a tendency to be older and feature long-term well being prerequisites.

Throughout states, the proportion of dual-eligible folks that use the non-LTSS wraparound services and products, imaginative and prescient, dental, and NEMT, levels from the low unmarried digits to just about part (Determine 4). Such variation might stem from Medicaid protection and administrative insurance policies as states with upper charges of use amongst dual-eligible folks even have upper charges of use amongst different Medicaid enrollees (Appendix Determine 2).

• Imaginative and prescient. The share of full-benefit dual-eligible people who use Medicaid wraparound imaginative and prescient services and products levels from 7% in South Carolina to just about 50% in Minnesota, which might mirror, partly, variations in Medicaid protection of vision services.
• Dental. The share of dual-eligible people who used Medicaid wraparound dental services and products levels from 1% or fewer in Florida and Alabama to 44% in Connecticut and Minnesota, additionally reflecting, partly, variations in protection of adult dental benefits. A few of the 14 states with fewer than 10% of dual-eligible folks the use of dental services and products, all however one state had both no coverage of grownup dental advantages or emergency-only protection.
• Non-Emergency Clinical Transportation. The share of full-benefit dual-eligible people who use NEMT levels from 1% or fewer of dual-eligible folks in Utah, New Hampshire, and Pennsylvania to 47% in Minnesota. Different research have discovered that there’s important variation in NEMT access throughout states, but in addition important variation in states’ reporting of NEMT use.

Variation throughout states in using wraparound services and products displays a bunch of things together with components which are commonplace throughout all Medicaid enrollees irrespective of whether or not they’ve Medicare, but in addition together with components which are distinctive to dual-eligible folks. States that experience upper percentages of dual-eligible folks the use of wraparound services and products frequently have upper use charges amongst Medicaid-only enrollees who’re eligible as a result of they’ve a incapacity or are ages 65 and older (Appendix Determine 2). Similarities within the variation of use charges between dual-eligible folks and Medicaid-only enrollees spotlight the function of Medicaid-specific components in figuring out how readily other folks get right of entry to wraparound services and products. One of the components which are commonplace throughout all Medicaid enrollees irrespective of whether or not they’ve Medicare come with:

• States’ protection of every wraparound provider,
• States’ administrative insurance policies that make it more straightforward or tougher for other folks to get right of entry to the services and products,
• The choice of suppliers of every provider and their appointment availability (which displays states’ cost charges amongst different components), and
• The level to which information of services and products are utterly and correctly reported within the information.

Different components impact charges of provider use which are distinctive to dual-eligible folks together with:

• Other people’s want for services and products equivalent to LTSS, dental and imaginative and prescient services and products (which displays the traits of states’ dual-eligible folks),
• Twin-eligible folks’ consciousness of Medicaid wraparound provider availability and protection, and
• Twin-eligible folks’ get right of entry to to wraparound services and products in methods instead of Medicaid (equivalent to Medicare Benefit plans).

How does using wraparound services and products range throughout dual-eligible folks with other demographic traits?

Complete-benefit dual-eligible people who are Hispanic use Medicaid wraparound services and products at decrease charges than different racial and ethnic teams (Determine 5, Race/Ethnicity tab). Simplest part of dual-eligible people who are Hispanic get right of entry to a number of wraparound services and products while over 60% of all different teams do. The whole disparity displays variations in use charges for all particular provider sorts, which might be beneath 10% for institutional LTSS and NEMT, 16% for dental care, and beneath 25% for HCBS and imaginative and prescient services and products. Twin-eligible people who are Asian even have low use charges for institutional LTSS (5%) and NEMT (6%), however 23% use dental services and products, 27% use imaginative and prescient services and products, and just about one-third use HCBS. The easiest charges of provider use are amongst twin eligible people who are American Indian or Alaskan Local (65% total which displays top charges of imaginative and prescient provider use), White (64% total which displays top charges of institutional LTSS use), and Local Hawaiian or Different Pacific Islander (64% which displays top charges of HCBS use). (Those charges are a few of the 29 states that reported “low/medium worry” with the standard in their race and ethnicity information in 2019; those 29 states account for 66% of the dual-eligible inhabitants; see Methods for added main points).

Twin-eligible folks ages 65 and older use institutional LTSS at a fee this is over thrice upper than the speed for the ones beneath age 65 (16% when put next with 5%), however they use dental services and products at a decrease fee (Determine 5, Age tab). The share of dual-eligible people who use a number of wraparound services and products is 63% for the ones ages 65 and older and 59% for the ones beneath age 65. Variations in use charges are small for HCBS, imaginative and prescient services and products, and NEMT, however greater for dental services and products: 24% of the ones beneath age 65 use dental services and products when put next with 17% of the ones ages 65 and older.

Amongst all dual-eligible folks with complete Medicaid, women use wraparound services and products at upper charges than men, however amongst the ones beneath age 65, charges of LTSS use are reasonably upper for men (Determine 5, Intercourse and Age & Intercourse tabs). When age isn’t accounted for, women and men use person services and products at equivalent charges, however the next proportion of women use a number of provider (64% when put next with 58%). When women and men are grouped through age, men beneath age 65 have reasonably upper charges of LTSS use (each institutional and HCBS), however decrease charges of use for different services and products and decrease charges of use total.

What are the coverage implications of variation in use of Medicaid wraparound services and products?

Medicaid supplies wraparound services and products equivalent to long-term services and supports, vision and dental care, and non-emergency scientific transportation for dual-eligible people who generally tend to have low incomes, top charges of long-term disabilities, and persistent prerequisites. A few of the 7.2 million dual-eligible folks with no less than 10 months of complete Medicaid, 61% (4.4 million other folks) use no less than one Medicaid wraparound provider; alternatively, use varies significantly through form of provider and throughout states. The adaptation throughout states is also because of quite a lot of components, together with variations in peoples’ well being standing, demographic traits, states’ protection of quite a lot of services and products, enrollees’ consciousness of Medicaid’s advantages, and form of Medicare protection amongst dual-eligible beneficiaries.

What do charges of wraparound provider use counsel in regards to the well being and wellbeing of dual-eligible folks and possible disparities amongst quite a lot of teams? Twin-eligible people who are Hispanic have decrease charges of use for all wraparound services and products as do other folks dwelling in positive states, however it’s unknown whether or not the ones decrease charges mirror limited access to care, difficulty in navigating care and advantages around the two methods, or decrease ranges of want between other teams. For many services and products, the adaptation throughout states in charges of use is the same amongst dual-eligible folks and Medicaid enrollees with out Medicare who’re eligible as a result of their age or incapacity. The ones similarities counsel that individual options of state Medicaid methods—equivalent to protection ranges, the supply of suppliers that take Medicaid, and the convenience of having access to Medicaid services and products—might play some function in figuring out what proportion of dual-eligible folks get right of entry to wraparound services and products inside of a given state.

What are the consequences of variation in using Medicaid wraparound services and products throughout states for dual-eligible people who are enrolled in conventional Medicare? In keeping with a separate KFF research, 55% of dual-eligible folks with complete Medicaid advantages had been in conventional Medicare in 2020, and the remainder 45% had been in Medicare Benefit plans. For full-benefit dual-eligible folks in conventional Medicare, Medicaid would give you the wraparound services and products incorporated on this research. Twin-eligible folks in conventional Medicare can have much less get right of entry to to those services and products in the event that they reside in states that don’t be offering those advantages or the place Medicaid protection of wraparound advantages is extra restricted than in different states with extra beneficiant advantages.

What are the consequences of the supply of Medicaid wraparound services and products for dual-eligible folks in Medicare Benefit plans? In keeping with a separate KFF analysis, Medicare Benefit plans be offering probably the most wraparound services and products analyzed right here, equivalent to dental and imaginative and prescient, however normally now not LTSS. Doable overlap between Medicare Benefit supplemental advantages and Medicaid wraparound services and products has triggered considerations amongst advocates and policymakers that enrollees in those plans will not be getting the entire supplement of wraparound advantages if advantages aren’t smartly coordinated between Medicare Benefit plans and Medicaid. Additional, there may be some worry that Medicare Benefit plans is also advertising those supplemental advantages to draw dual-eligible folks, although those beneficiaries might have already got get right of entry to to those advantages coated beneath their state Medicaid program. (Word that this research isn’t ready to investigate how use of Medicaid wraparound services and products through dual-eligible folks differs for other folks with conventional Medicare or Medicare Benefit.)

What does variation in Medicaid protection throughout states counsel for ongoing coverage proposals to create new Medicare dental, imaginative and prescient, or HCBS advantages? In recent times, policymakers have proposed including new advantages to the Medicare advantage bundle together with:

• HCBS within the Make a choice House Care Act of 2021 (R. 5514 and S.2562), and Increasing Care within the House Act (H.R. 2853)
• Dental and imaginative and prescient care within the Medicare and Medicaid, Dental, Imaginative and prescient and Listening to Receive advantages Act of 2023 (S.842 and H.R.33) and the Medicare Dental Receive advantages Act of 2023 (H.R. 4146).

New Medicare advantages may just build up get right of entry to to those services and products for Medicare beneficiaries total, however the results on dual-eligible folks would rely at the generosity of protection of their state’s Medicaid program and whether or not states lowered their protection of wraparound services and products in accordance with Medicare advantage adjustments.