Analysis of Pathways to Dual Eligible Status: Final Report

05/09/2019

There are multiple pathways to becoming dually eligible for Medicare and Medicaid. The purpose of this study is to identify the frequency with which these pathways are followed and the beneficiary characteristics and patterns of service use by pathway. We used the Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) to identify individuals who became dually eligible for Medicare and full Medicaid benefits, during 2007-2010. We categorized these individuals by temporal pathway: (1) Medicare-to-Medicaid, (2) Medicaid-to-Medicare, and (3) simultaneous transition to full-dual status. We identified beneficiary reason for eligibility, demographic characteristics, and service use around the time of initial transition to full-dual status.

Reasons for Medicaid and Medicare eligibility, age, presence of chronic conditions, and service use at time of initial transition to full-dual status vary by pathway, suggesting that different subgroups of dually eligible beneficiaries may have different care needs. About one-quarter of duals experienced some eligibility gap in the 12 months following transition to full-dual status.

Transitioning from Medicare to full Medicaid coverage is likely related to the use of expensive uncovered medical care and LTSS. Medicaid pays for such services for many beneficiaries long before they become Medicare eligible. Understanding these differences can inform interventions to support the dual eligible population and individuals at risk of becoming duals. The finding that some do not maintain full-dual eligibility suggests that some duals may face gaps in care.

This report was prepared under contract #HHSP23320100021WI between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Research Triangle Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact the ASPE Project Officer, Jhamirah Howard, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201; Jhamirah.Howard@hhs.gov.

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on March 2017.

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