SECTION NEWS & NOTES
President’s Perspective: Dual Eligible - What Does It Mean and Why Should You Know About It? Deborah S. Larsen
I
n June, the Neurology Section brought forward to the APTA’s House of Delegates a resolution and a motion to focus attention on and direct advocacy toward meeting the needs of those with chronic disability who are dual eligible (DE) under the Medicare and Medicaid systems. Frequently, through the posting and subsequent approval processes, there were questions about what was meant by “dual eligible” and why the Section wanted to focus attention on this issue. In this President’s perspective, I have chosen to respond to those questions. First, dual eligibility refers to Medicaid coverage for those also eligible for Medicare. Although we tend to think of Medicare as coverage for those older than 65 years, there are a growing number of younger individuals with chronic disability who are now covered through Medicare. These are individuals who have qualified for Social Security Income Assistance for at least 24 months before becoming eligible for Medicare. Of this group of under-65 Medicare recipients, one third or more are DE. There are also a growing number of the oldest old, those older than 85 years, who are also DE. For all of those who are DE, Medicare is the primary insurer with Medicaid assisting in cost-sharing as well as assistance with coverage of Medicare premiums. Some individuals who are DE receive full Medicaid coverage, whereas others only receive partial coverage, which does not cover hearing, vision, dental, or long-term care.1 Individuals who are DE tend to be medically complicated, often with 4 or more diagnoses, and many with chronic neurologic disorders (eg, poststroke, spinal cord injury, and multiple sclerosis) with or without mental (eg, retardation and dementia) or psychological disorders; in fact, recent estimates suggest that 40% to 50% of DE enrollees are disabled. Notably, individuals who are DE are more likely to be women, nonwhite, single, and less well educated,2 with an estimated 9.6 million individuals meeting eligibility criteria.2 Yet, these 9 million account for more than 35% of the spending by both the Medicaid and Medicare systems.3 So, it would seem that those meeting the criteria for dual eligibility would be adequately covered for their medical needs. Right? Not necessarily. One of the many challenges for these individuals is the complexity of the rules governing the Medicare and Medicaid systems. As a reminder, Medicaid is a
state-run system with state-specific regulations, whereas Medicare is a federally run system. This fragmentation of the 2 systems often results in poor coordination of care, characterized by providers and provider systems that do not communicate with each other; further, dual eligibility may mean different coverage by individual and by state. It has been noted that enrollees could have “three ID cards (Medicare, prescription drugs, Medicaid), three different sets of benefits, and multiple providers.”3(p.222) Interestingly, although Medicaid pays for long-term care, Medicare pays for hospitalizations; it has been suggested that this is a disincentive to avoid hospitalizations for those in long-term care, often for avoidable infections or conditions. This process, known as cost-shifting, likely results in overall poorer quality of care for the enrollees who are DE.3 This is just one example of the challenges of dual coverage and limited coordination of services; however, it is critical that we develop an integrated care system that streamlines the coverage for DEs, who are our most needy consumers of medical care, and to include within that system coverage for health promotion and maintenance. The Neurology Section’s Board of Directors brought this critical issue forward because many of those who qualify for dual eligibility are also in need of long-term rehabilitation from physical therapists to improve, or, at the minimum, maintain their health, including the prevention of secondary health consequences and the provision of appropriate assistive technology to maximize function. The APTA is well positioned to advocate for change in health care policy to develop an integrated care system as well as to ensure that long-term coverage for physical therapy services is made available for those who need our services the most—those living with chronic disabilities. REFERENCES 1. Young K, Garfield R, Musumeci M, Clemans-Cope L, Lawton E. Medicaid’s role for dual eligible beneficiaries. The Kaiser Family Foundation. http:// www.kff.org. Accessed October 10, 2013. 2. Moon S, Shin J. Health care utilization among Medicare-Medicaid dual eligibles: a count data analysis. BMC Public Health. 2006;6:88-98. 3. Grabowski DC. Care coordination for dually eligible Medicare-Medicaid beneficiaries under the affordable care act. J Aging Soc Policy. 2012;24: 221-232.
C 2014 Neurology Section, APTA. Copyright ISSN: 1557-0576/14/38000-0100 DOI: 10.1097/NPT.0000000000000028
100
JNPT r Volume 38, January 2014 Copyright © 2014 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
President’s Perspective: Dual Eligible - What Does It Mean and Why Should You Know About It? Deborah S. Larsen
I
n June, the Neurology Section brought forward to the APTA’s House of Delegates a resolution and a motion to focus attention on and direct advocacy toward meeting the needs of those with chronic disability who are dual eligible (DE) under the Medicare and Medicaid systems. Frequently, through the posting and subsequent approval processes, there were questions about what was meant by “dual eligible” and why the Section wanted to focus attention on this issue. In this President’s perspective, I have chosen to respond to those questions. First, dual eligibility refers to Medicaid coverage for those also eligible for Medicare. Although we tend to think of Medicare as coverage for those older than 65 years, there are a growing number of younger individuals with chronic disability who are now covered through Medicare. These are individuals who have qualified for Social Security Income Assistance for at least 24 months before becoming eligible for Medicare. Of this group of under-65 Medicare recipients, one third or more are DE. There are also a growing number of the oldest old, those older than 85 years, who are also DE. For all of those who are DE, Medicare is the primary insurer with Medicaid assisting in cost-sharing as well as assistance with coverage of Medicare premiums. Some individuals who are DE receive full Medicaid coverage, whereas others only receive partial coverage, which does not cover hearing, vision, dental, or long-term care.1 Individuals who are DE tend to be medically complicated, often with 4 or more diagnoses, and many with chronic neurologic disorders (eg, poststroke, spinal cord injury, and multiple sclerosis) with or without mental (eg, retardation and dementia) or psychological disorders; in fact, recent estimates suggest that 40% to 50% of DE enrollees are disabled. Notably, individuals who are DE are more likely to be women, nonwhite, single, and less well educated,2 with an estimated 9.6 million individuals meeting eligibility criteria.2 Yet, these 9 million account for more than 35% of the spending by both the Medicaid and Medicare systems.3 So, it would seem that those meeting the criteria for dual eligibility would be adequately covered for their medical needs. Right? Not necessarily. One of the many challenges for these individuals is the complexity of the rules governing the Medicare and Medicaid systems. As a reminder, Medicaid is a
state-run system with state-specific regulations, whereas Medicare is a federally run system. This fragmentation of the 2 systems often results in poor coordination of care, characterized by providers and provider systems that do not communicate with each other; further, dual eligibility may mean different coverage by individual and by state. It has been noted that enrollees could have “three ID cards (Medicare, prescription drugs, Medicaid), three different sets of benefits, and multiple providers.”3(p.222) Interestingly, although Medicaid pays for long-term care, Medicare pays for hospitalizations; it has been suggested that this is a disincentive to avoid hospitalizations for those in long-term care, often for avoidable infections or conditions. This process, known as cost-shifting, likely results in overall poorer quality of care for the enrollees who are DE.3 This is just one example of the challenges of dual coverage and limited coordination of services; however, it is critical that we develop an integrated care system that streamlines the coverage for DEs, who are our most needy consumers of medical care, and to include within that system coverage for health promotion and maintenance. The Neurology Section’s Board of Directors brought this critical issue forward because many of those who qualify for dual eligibility are also in need of long-term rehabilitation from physical therapists to improve, or, at the minimum, maintain their health, including the prevention of secondary health consequences and the provision of appropriate assistive technology to maximize function. The APTA is well positioned to advocate for change in health care policy to develop an integrated care system as well as to ensure that long-term coverage for physical therapy services is made available for those who need our services the most—those living with chronic disabilities. REFERENCES 1. Young K, Garfield R, Musumeci M, Clemans-Cope L, Lawton E. Medicaid’s role for dual eligible beneficiaries. The Kaiser Family Foundation. http:// www.kff.org. Accessed October 10, 2013. 2. Moon S, Shin J. Health care utilization among Medicare-Medicaid dual eligibles: a count data analysis. BMC Public Health. 2006;6:88-98. 3. Grabowski DC. Care coordination for dually eligible Medicare-Medicaid beneficiaries under the affordable care act. J Aging Soc Policy. 2012;24: 221-232.
C 2014 Neurology Section, APTA. Copyright ISSN: 1557-0576/14/38000-0100 DOI: 10.1097/NPT.0000000000000028
100
JNPT r Volume 38, January 2014 Copyright © 2014 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
