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Covering the Dual-Eligible Population

Dual eligibles are persons who qualify, in some way, for both Medicare and Medicaid coverage. Medicare covers their acute care services, while Medicaid covers Medicare premiums and cost sharing, and—for those below certain income and asset thresholds—long-term care and other services.

Currently, there are approximately 9 million dual eligibles in the United States, accounting for:

  • 19 percent of Medicare beneficiaries, but 31 percent of Federal Medicare spending.  
  • 15 percent of Medicaid enrollees but  40 percent of Medicaid spending
  • An average per member, per year cost of $33,000 (compared with $8,000 PMPY for standard Medicare beneficiaries
  • Approximately $300 billion in combined Federal Medicare, and Federal-state Medicaid spending.

 

Dual-eligible beneficiaries' health care services must be coordinated across Medicare and Medicaid, two separately governed and funded programs, each with its own set of covered services, provider fee schedules and networks regulations, and payment policies. 

To gain a better understanding of this population, as well as the opportunities and challenges they present to health plans, we've developed the attached whitepaper. 

 

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