A recent brief from Kaiser Family Foundation (KFF) provides a profile of dual eligibles, which includes people who are jointly enrolled in Medicare and Medicaid. These 12.5 million Medicare-Medicaid enrollees are referred to as dual eligibles because, once enrolled, they are eligible for benefits under two separate programs. Here we summarize the process for becoming dual eligible, common characteristics of dual eligibles, and conclusions from the brief.
Becoming Dually Eligible
“To be eligible for full Medicaid benefits, Medicare beneficiaries must meet states’ Medicaid eligibility criteria. States are required to cover Medicare beneficiaries who receive Supplemental Security Income, and may choose to cover additional groups such as people with income less than the federal poverty level and those who need long-term services and supports.”
Once someone has been designated as dually eligible, they also typically qualify for the Medicare Savings Program, which provides Medicare premium and cost-sharing assistance. The Medicare Savings Program is administered by each state; however, “minimum income and resource limits” for inclusion in the program are set by the federal government.
These limits are adjusted annually by the Centers for Medicare and Medicaid Services (CMS). The 2022 limits were defined as follows:
“Medicare beneficiaries had to have income below $1,549 each month for an individual ($2,080 for a couple) and resources below $8,400 for an individual ($12,600 for a couple).”
States do have the ability to raise their limits above the number set by the federal government to enable more individuals to qualify by using a higher income eligibility criteria.
Common Characteristics
KFF examined dual eligibles across three characteristics:
- Demographic details
- Socioeconomic (e.g., income) levels
- Health status
They were then able to identify common characteristics among dual eligibles and highlighted the following key takeaways:
- Among all dual eligibles, 87% earn less than $20,000 per year.
- More than 1 in 10 dual eligibles (13%) resided “in a long-term care nursing home or other institutional facility.”
- Nearly 40% of dual eligibles were less than 65 years of age and had qualified for Medicare after receiving long-term disability payments for 24 months.
- More than half (51%) of dual eligibles identified as people of color.
- 44% of dual eligibles were considered in fair or poor health. Among full-benefit dual eligibles, 21% were considered in excellent or very good health. Among partial-benefit dual eligibles, the number reported as having excellent or very good health was 27%.
- Nearly half of all dual eligibles (48%) “had at least one limitation in activities of daily living (ADLs)” and more full-benefit enrollees had two or more limitations in ADLs than partial-benefit enrollees (40% vs. 23%, respectively).
- Over a quarter (26%) of dual eligibles had 5 or more “chronic conditions.”
- Exactly half of dual eligibles reported having at least one mental health condition.
- Approximately 1 in 6 (16%) of full-benefit dual eligibles were individuals with intellectual or developmental disabilities (I/DD).
Key Conclusions
In examining the data, KFF concluded that the majority of dually-eligible enrollees were more likely than beneficiaries only using Medicare to:
- Have lower incomes;
- Identify as racially or ethnically diverse;
- Be in poorer health;
- Possess greater health needs;
- Live with a serious mental health or physical condition; and
- Reside in an institutional setting.
The diversity in means, circumstances, and needs among the 12.5 million beneficiaries designated as dual eligibles poses a challenge for policy-makers and legislators in “developing targeted strategies to improve the coordination and management of care.” This is especially true in balancing calls from various stakeholders—such as advocates, government agencies, and providers—for greater simplicity, efficiency, and flexibility.
To read the full KFF report, click here.