This study examined the care management practices in four health plans that serve persons who are dually eligible for Medicare and Medicaid, commonly referred to as "dual eligibles." The project case studied two health plans in the Massachusetts Senior Care Options program (SCO)-Commonwealth Care Alliance and Senior Whole Health-and two in the Arizona Long Term Care System (ALTCS)-Mercy Care Plan and SCAN Long Term Care.
The authors describe how health plans operationalize their integrated care management approaches and highlights how care management is practiced at the point of service delivery. Approaches to care management are different across plans, in part reflecting differences in state program requirements and design. Despite these differences, the authors identify a common framework for integrating care for dual eligibilities. Within this framework, the authors present common themes employed by plans to manage both Medicare- and Medicaid-covered benefits, and common challenges.
Dual eligibles are particularly susceptible to fragmented care and could gain substantially from improved care management. Compared to persons who are eligible for Medicare only, dual eligibles are much more likely to be in poor health, not have a spouse, have impairments in activities of daily living, have less than a high school education, and suffer from cognitive impairments or mental disorders. The 8.1 million persons who are dual eligibles represent disproportionate spending in both programs. They make up 18 percent of the Medicaid population but represent 46 percent of Medicaid expenditures. In Medicare, they comprise 16 percent of the population but account for 27 percent of all expenditures
In addition, many dual eligibles require long-term care services, which are financed under Medicaid, while most of their medical care is financed under Medicare. Consequently, care management for dual eligibles are more complex than for Medicare-only persons as they receive care from two separate public financing systems, with differing benefits, provider networks, payment incentives, and policy objectives.