As U.S. healthcare providers shift to value-based care, they need to keep up with various governmental funding plans that could increase options for patients.

For example, some states create opportunities for dual-eligible beneficiaries to join Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) and Medicaid plans operated by the same insurer. Researchers suggest these plans can decrease inpatient admissions and nursing home admissions.1

“These are a unique type of Medicare Advantage plans that exclusively enroll dual-eligible beneficiaries,” says Laura M. Keohane, PhD, assistant professor of health policy at Vanderbilt University School of Medicine. “They are low-income Medicare beneficiaries who have Medicare as their primary source of insurance for services like hospitalizations. Medicaid is their secondary source of insurance for helping with out-of-pocket costs and extra services that aren’t covered by Medicare. These include long-term care services and support.”

For example, a patient might stay in the hospital for three days. Medicare would pick up coverage for the rehabilitation stay under the Medicare Skilled Nursing Facility Benefits for up to 100 days, Keohane says.

“If the person stays in the nursing home and is a dual-eligible beneficiary, Medicaid becomes the insurer of the long-term stay at the nursing home,” she explains. “Dual-eligible beneficiaries can either be in traditional Medicare, where your benefits are administered by the medical federal program directly, or they can be in Medicare Advantage, where they get their benefits through a managed care plan.”

Case managers should know of this option for their dual-eligible clients. These types of plans can help enhance case management.

“Some D-SNPs may hire care coordinators directly in the plan to help oversee organization of benefits across different providers,” Keohane says. Also, case managers who are familiar with dual-eligible beneficiaries and plans could recommend this program to some of their older patients.

Researchers studying dual-eligible plans found that few enrollees who live in nursing homes were using these plans, even though that population could benefit from such plans.1

Some Medicare Advantage plan limitations include extra premiums that could vary across states. Some plans include opt-in coverage that makes it difficult to reach nursing home populations, Keohane explains. Most states require beneficiaries of these plans to have an income level between 75% to 100% of the federal poverty level.

“If you have income above that level but have high nursing home expenses, you can qualify for Medicaid based on your income after you pay out of pocket for nursing home expenses,” she explains.

Right now, 11 states are using the D-SNP and Medicaid plans, covering approximately 690,000 people.1

“For most beneficiaries, it probably would not involve extra premium costs to be in one of these dual-eligible plans,” Keohane says. “It might have some extra benefits they couldn’t get through traditional Medicare or Medicaid, like limited access to dental care.”

REFERENCE

  1. Keohane L M, Zhou Z, Stevenson DG. Aligning Medicaid and Medicare Advantage managed care plans for dual-eligible beneficiaries. Med Care Res Rev 2021;10775587211018938. doi: 10.1177/10775587211018938. [Online ahead of print].