Dual Eligibility refers to a person being eligible in some way for both Medicare and Medicaid. Medicare is a federal program while Medicaid is a state program that is available to those with low income and/or resources.
Medicare and Medicaid
Medicare covers acute care services and Medicaid covers Medicare premiums and cost sharing expenses. Medicaid may also cover expenses for long term care.
There are different types of eligibility and this link goes to a report with a table that outlines the differences
http://www.medpac.gov/publications%5Ccongressional_reports%5CJune04_ch3.pdf
Medicare is considered the primary insurer and covers medically necessary acute care services, including physician, hospital, hospice, SNF, home health services as well as durable medical equipment (DME).
Medicaid is the secondary payer and covers services that are not covered by Medicare. Examples include transportation, dental and vision. There may be coverage for services not covered by Medicare as well as care after the Medicare benefit is exhausted or if certain Medicare criteria are not met. Types of services may include hospital, nursing home or home health care.
Medicare-Medicaid Coordination Office
The Federal Coordinated Health Care Office, also known as the Medicare-Medicaid Coordination Office, serves people who receive benefits from both Medicaid and Medicare. A person covered by both has dual eligibility. The goal for this office is to make sure that people with limited income and resources have full access to seamless, high quality health care while making the system as cost-effective as possible.
The Medicare-Medicaid Coordination Office works with each state’s Medicaid program and all federal agencies to help coordinate benefits between the two programs effectively and efficiently. Work is being done to create new care models and to improve the way those who are dual eligible receive health care.
The Medicare-Medicaid Coordination Office was created as part of the Affordable Care Act. The goals include the following for those who are dual eligible:
- Assure full access to available benefits
- Simplify processes to access items and services
- Improve health care quality and services
- Increase understanding of programs and improve satisfaction with coverage
- Solve rule conflicts between state and federal programs
- Improved continuity of care and safe care transitions among health care providers
- Improved provider performance and care quality
Special Programs
The Program of All-Inclusive Care for the Elderly (PACE) serves frail elderly beneficiaries, age 55 and older, who meet states’ standards for nursing home placement and live in areas served by the PACE organizations.
State Demonstration Waivers have been created and operate under the Medicare demonstration authority. Typically these programs use a model based on a different type of fee schedule to improve coordination of services. Examples include the Minnesota Senior Health Options and the Wisconsin Partnership Program.
Evercare is a demonstration project that provides case management for those living in nursing homes. The goal is to reduce the need for hospital and emergency room care. Nurse practitioners work closely with primary care physicians and the project has shown that hospitalizations decreased when compared with control groups and that care is at least comparable to what is available to those not in the demonstration project. It currently operates in 11 states with 24,000 enrolled.
References
About the Medicare-Medicaid Coordination Office:
http://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/index.html
Understanding the Affordable Care Act http://www.healthcare.gov/law/introduction/index.html
Dual Beneficiaries Overview: http://www.medpac.gov/publications%5Ccongressional_reports%5CJune04_ch3.pdf
The Kaiser Foundation on Medicaid Facts:
http://www.kff.org/medicaid/upload/4091-04%20Final(v2).pdf
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