Medicare primarily covers the elderly, the disabled, and people with end-stage renal disease. Medicaid covers low-income people. So who is dual eligible, eligible for both programs?
The Medicaid and CHIP Payment and Access Committee (MACPAC) and the Medicare Payment Advisory Committee (MedPAC) proposed a Report A summary of the characteristics, spending and health care utilization of these dual-qualifiers was provided last year.
First, the report describes who pays what for dual qualification:
For dual-eligible beneficiaries, Medicare is the primary payer for the acute and post-acute care services covered by the plan. Medicaid provides varying levels of assistance through Medicare premiums and cost-sharing, and for many beneficiaries, also covers services not covered by Medicare benefits, such as long-term services and supports (LTSS). Full-benefit dual-eligible beneficiaries receive the full range of Medicaid benefits offered by specific states. For dual-eligible beneficiaries with partial benefits, Medicaid pays Medicare premiums and may also pay a share of the cost of Medicare services.
For dual-qualifiers, Medicaid can be considered a wraparound insurance that covers certain services and cost-sharing that Medicare doesn’t. The table below summarizes which services are covered by which plan.
In 2019, 12.2 million beneficiaries were dual eligible throughout the year. This represents 19.3% (12.2 million of 63.1 million) of Medicaid beneficiaries or 13.6% (12.2 million of 89.8 million) of Medicare beneficiaries. While more than 92% of Medicare individuals are 65 and older, only 62% of individuals in dual eligibility are 65 and older. For Medicaid beneficiaries who are not dual eligible, only 1.2% are 65 and older. Additionally, while only 15 percent of non-dual-eligible beneficiaries were eligible for Medicare coverage due to disability, 51 percent of dual-eligible beneficiaries were eligible for Medicare due to disability. More detailed demographic information follows.
Medicare spending is significantly higher for dual-eligible beneficiaries compared to non-dual-eligible beneficiaries. Spending was $10,887 (107 percent) higher for non-ESRD individuals than for non-double spending, and $26,650 (41 percent) higher for ESRDs, as shown in the chart below. Total spending on dual eligibility was $440.2 billion, with Medicare paying $275.9 billion and Medicaid paying $164.3 billion.
In terms of health and education, dual-qualifiers were significantly sicker and less educated.
The full report has more useful graphics, you can read it here.
