The Opportunity to Improve Care

There are about 12 million dual eligible beneficiaries enrolled in both Medicare and Medicaid. This is a diverse population that includes people with multiple chronic conditions, developmental and physical disabilities, mental illness, cognitive impairments, and social needs.  

• According to the Centers for Medicare and Medicaid Services (CMS), 41 percent of dual eligible individuals have at least one mental health diagnosis and 60 percent have multiple chronic conditions.  

• More than half of dual eligible individuals qualify for Medicare on the basis of disability (51 percent) compared to only 15 percent of non-dual Medicare beneficiaries, and nearly half of duals have limitations in performing Activities of Daily Living (47 percent), compared to just 18 percent of non-dual Medicare beneficiaries.  

• Dual eligible individuals experience socioeconomic disadvantages, with 57 percent of duals living below the federal poverty level and 45 percent reporting food insecurity. 

• Dual eligible individuals tend to have a high level of medical care needs, compared to their Medicare-eligible, non-dual peers, as indicated by their share of program spending in both Medicare and Medicaid. Whereas duals made up 19 percent of beneficiaries in the Medicare program, 35 percent of Medicare spending was attributed to their care in CY 2021. Similarly, they made up 13 percent of Medicaid beneficiaries, but 27 percent of Medicaid spending.

Both MedPAC and MACPAC have raised concerns with how separate funding streams creates barriers to coordination of care and the extent to which lack of coordination increases costs and leads to poor health outcomes. Numerous researchers, health policy experts, states, and stakeholders have expressed interest in seeing more aligned incentives and integrated care to improve health outcomes and quality of care for dual eligible beneficiaries. 

The Comprehensive Care for Dual Eligible Individuals Act

The Coalition proudly supports federal legislation that will meaningfully improve integration for dual eligibles. 

• Comprehensive Care for Dual Eligible Individuals Act – This legislation provides states the option to develop an All-Inclusive, Integrated Medicare-Medicaid (AIM) Program, where states can—with robust CMS oversight—administer a single integrated program for full benefit dual eligible beneficiaries, such that beneficiaries would no longer have to navigate separate programs to meet their complex needs. The Coalition fully supports this legislation as a critical step for states to integrate program financing, administration, eligibility processes, and benefits to create the most comprehensive, integrated benefit possible for dual eligible beneficiaries with the most complex needs. This legislation incorporates the Coalition’s framework and policy recommendations on the creation of a single, integrated option for duals.  
• DUALS Act – This legislation requires each state to select, develop, and implement a comprehensive, integrated health plan for dual-eligible beneficiaries. It permits states to create a new system or build on existing coverage options, and states are required to develop and update care coordination plans, establish an ombudsman office, and a care coordinator for each beneficiary. The legislation also creates a single appeals process for dual beneficiaries. The Coalition is supportive of the Senate Working Group’s ongoing efforts to develop comprehensive legislation to drive duals integration forward. The Coalition supports this legislation’s inclusion of a single appeals process, notification requirements for beneficiaries, and requirements for the establishment and funding of an ombudsman office responsible for assisting duals and their caregivers.  
• AIM Act – This legislation requires states to develop a strategy to integrate and coordinate Medicaid and Medicare coverage for full-benefit dual eligible individuals, and include in the strategy the main integration approach, eligibility requirements, patient education and enrollment plan, patient choice protections, mental health benefit coordination, and data collection and measurement. The legislation would also require states submit the plan to HHS for review, approval, and continued evaluation over time. The Coalition supports this legislation as a measure that would spur state deliberation, planning, and innovations to better meet the needs of duals.  
• Helping States Integrate Medicare and Medicaid Act – This legislation requires states to develop a strategy for Medicare and Medicaid integration, and provides funding for development of integration plans, in line with recommendations from the Medicaid and CHIP Payment and Access Commission (MACPAC). The legislation increases the federal match that states receive to 80 percent for administrative activities to support the implementation and advancement of these integration strategies and to finance the initial costs of building an infrastructure that is reflective of the needs and preferences of the local Medicare-Medicaid population. The Coalition supports this legislation as a step that will support states in a process to improve integration.  

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