At the Intersection of Health, Health Care and Policy Cite this article as: Gerald F. Riley, Lirong Zhao and Negussie Tilahun Understanding Factors Associated With Loss Of Medicaid Coverage Among Dual Eligibles Can Help Identify Vulnerable Enrollees Health Affairs, 33, no.1 (2014):147-152 doi: 10.1377/hlthaff.2013.0396
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Medicaid Coverage By Gerald F. Riley, Lirong Zhao, and Negussie Tilahun 10.1377/hlthaff.2013.0396 HEALTH AFFAIRS 33, NO. 1 (2014): 147–152 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Understanding Factors Associated With Loss Of Medicaid Coverage Among Dual Eligibles Can Help Identify Vulnerable Enrollees For people who receive both Medicare and Medicaid benefits (dual-eligible beneficiaries), the loss of Medicaid coverage may lead to problems with care coordination, higher out-of-pocket expenses, or reduced access to services. Using administrative data, we followed 292,242 full-benefit and 91,020 partial-benefit dual eligibles from January 2009 through December 2011. Among those with full Medicaid benefits, 15.6 percent lost Medicaid coverage at least once, with more frequent losses among younger beneficiaries. Many of these losses lasted only one to three months and were followed by reinstatement. Loss of Medicaid coverage was more common (23.2 percent) among enrollees with partial Medicaid benefits. Medicare Current Beneficiary Survey data indicate that most dual eligibles who lost Medicaid coverage had no other source of supplemental insurance. Medicaid coverage is relatively stable among dual eligibles. However, some lose Medicaid for several months or more, putting them at risk for poor outcomes and potentially complicating their care, especially when it needs to be integrated under the two programs. ABSTRACT
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eople receiving both Medicare and Medicaid benefits (known as dualeligible beneficiaries) have been the subject of extensive policy interest because of their poor health, complex care needs, and high costs.1 In addition, this population is characterized by low incomes and a lack of private health insurance and thus is vulnerable to problems with access to care.2,3 Most dual eligibles have full Medicaid benefits that include coverage of long-term care services and most Medicare cost-sharing and premium expenses. Twenty-seven percent have partial benefits, receiving Medicaid support only for Medicare cost sharing, premiums, or both.4 Per capita spending for dual eligibles (with either full or partial benefits) in 2009 was estimated to be $15,743 and $13,564 under Medicare and Medicaid, respectively—much higher than spending for other Medicare beneficiaries.5
Gerald F. Riley (gerald.riley@ cms.hhs.gov) is a social science research analyst at the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, in Baltimore, Maryland. Lirong Zhao is a quantitative research analyst at the Center for Medicare and Medicaid Innovation. Negussie Tilahun is a social science research analyst at the Center for Medicare and Medicaid Innovation.
Historically, health care for dual eligibles has suffered from a lack of coordination on several levels. A lack of clinical integration of acute and long-term care has led to inefficiencies and lower quality of care.6 And a lack of financial integration of payments under Medicare and Medicaid has produced conflicting program incentives and cost shifting that might raise overall costs.7 Differences in Medicare and Medicaid administrative structures have created barriers to improvement. Accordingly, coordination of care under the two programs has been the focus of several special policy initiatives, such as Dual Eligible Special Needs Plans (D-SNPs) and the Program of All-Inclusive Care for the Elderly. More recently, the Centers for Medicare and Medicaid Services (CMS) has begun testing payment and service delivery models that integrate care and funding under Medicare and Medicaid.8,9 J a n u a ry 2 0 1 4
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Medicaid Coverage Medicare enrollees seldom leave the program. However, Medicaid coverage can be more volatile because of beneficiaries’ fluctuations in income, changes in eligibility status, or failure to apply for renewal of Medicaid eligibility in a timely manner. Bruce Stuart and Puneet Singhal3 reported a rate of Medicaid disenrollment among dual eligibles of 5.4 percent per year. Loss of Medicaid coverage might undermine integrated programs of care for dual eligibles and thwart efforts to improve the efficiency of care delivery for them. Their access to care might also be compromised by their loss of coverage for long-term care services and increased liability associated with Medicare cost sharing and premiums, following the loss of Medicaid. This study used Medicare and Medicaid administrative data to examine several issues related to loss of Medicaid coverage in 2009–11 among dual eligibles with full or partial benefits. The following research questions were addressed: What percentage of dual eligibles lose Medicaid coverage, and for how long? What are the risk factors for such loss? How frequently is Medicaid coverage regained, and how much time elapses between loss of coverage and reinstatement? Do dual eligibles who lose Medicaid coverage have other supplemental insurance?
Study Data And Methods Data Our primary data source was the annual Master Beneficiary Summary File, which is part of the Medicare Chronic Conditions Data Warehouse10 and contains data on beneficiaries’ demographic characteristics and enrollment in Medicare, Medicare Advantage, and Medicaid. From the 2009 Master Beneficiary Summary File, we identified a cohort consisting of a 5 percent random sample of Medicare beneficiaries who resided in the United States, were entitled to Medicare Parts A and B, and were eligible for full or partial Medicaid benefits in January 2009. These 2009 records were linked to Master Beneficiary Summary File records for 2010–11 to permit follow-up through December 2011. Hierarchical Condition Category risk scores, which predict Medicare costs based on beneficiaries’ diagnoses and demographic characteristics, were obtained from internal CMS files as a proxy for health status.11 Medicaid Analytic Extract personal summary files for 2008 were also used to obtain the basis of Medicaid eligibility and to calculate monthly Medicaid fee-forservice costs prior to loss of coverage.12 These files were not available for the years after 2008 at the time of this study. The final sample size was 383,262 dual eligibles. Analyses The key outcome variable was loss 148
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of Medicaid coverage between January 2009 and the earliest occurrence of death, loss of Medicare Part A or B coverage, or December 2011. For fullbenefit dual eligibles, any loss of full Medicaid benefits was counted as a loss of Medicaid coverage, including a change from full-benefit to partial-benefit status. Exploratory analyses revealed two anomalies in the data set. First, a very high proportion of dual eligibles first lost Medicaid coverage in the month of death in several states in certain years. These situations were not counted as losses of Medicaid coverage in the analysis. Second, an implausibly high proportion of dual eligibles in Texas lost Medicaid coverage in 2011, usually for one month. We therefore followed Texas residents through 2010 only. Descriptive statistics and logistic regression were used to determine how often Medicaid coverage was lost and for how long, whether it was regained, and what the risk factors were for losing coverage. All analyses were stratified by level of Medicaid benefits (full or partial). We did this because of the differences in the two populations (income eligibility criteria are stricter for those with full benefits, so they tend to have lower incomes) and the different implications for the beneficiary of losing full or partial Medicaid benefits. We used data from the Medicare Current Beneficiary Survey to examine whether dual eligibles had any other sources of health insurance besides Medicare following loss of Medicaid coverage. This survey is a longitudinal, multipurpose survey of a nationally representative sample of the Medicare population.13 Respondents are asked about the source of any private or public health insurance they have besides Medicare and the type of that insurance, such as general, dental, or long-term care. Each respondent participates in up to four fall rounds of the survey; each round is summarized in annual Access to Care Files. We pooled data from these files for 2006–10. For the years 2006–09 we identified respondents who had full Medicaid benefits or partial benefits for Medicare cost sharing and who were not in their last year of Medicare Current Beneficiary Survey participation.We excluded partial-benefit enrollees who received Medicaid support for Medicare premiums only. We then identified which of the remaining respondents were without full Medicaid benefits or partial benefits for Medicare cost sharing in the subsequent fall round of the survey; there were 345. We calculated the percentage of beneficiaries in this group who reported having general private or public health insurance or long-term care insurance in the subsequent round. If respondents reported
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receiving health care services from the Department of Veterans Affairs at any time in the calendar year of the subsequent round (through the Medicare Current Beneficiary Survey Cost and Use Files), we counted that as the equivalent of having health insurance. All percentages were calculated using the survey’s longitudinal weights. Limitations Three limitations to our study should be kept in mind. First, we were unable to determine why dual eligibles lost their Medicaid coverage. Possible reasons include an increase in income or assets, failure to apply for renewal in a timely manner, changes in eligibility status, and improvements in health or a return to work for people under age sixty-five.We expect that different reasons for the loss of Medicaid coverage would provoke different policy responses. Second, we could not directly measure the impact of the loss of Medicaid coverage on health outcomes or access to care. And third, our findings were subject to the accuracy of Medicare administrative records and data reported by the various state Medicaid programs.
Study Results During the three-year follow-up period, 45,493 people with full benefits lost Medicaid coverage at least once (Exhibit 1). Multiplying the number from the 5 percent sample by 20 suggests that more than 900,000 dual eligibles lost full-benefit status in the study period. About half of those in the sample who lost full Medicaid benefits regained them, but more than 16 percent of those who lost full benefits did so more than once (Exhibit 1). Approximately 37 percent of all losses involved a transition from full-benefit to partial-benefit status (data not shown). Of those who lost full Medicaid benefits, 28.8 percent lost them for only one to three months, but 42.5 percent lost them for more than twelve months (Exhibit 1). Among those with partial Medicaid benefits, 23.2 percent lost Medicaid coverage, with 57.7 percent of them regaining coverage (Exhibit 1). Roughly one-third of these coverage losses lasted one to three months, and slightly more than one-third were for more than twelve months. Among dual eligibles with full Medicaid benefits, the probability of losing Medicaid coverage declined in higher age groups, from 21.3 percent for those under age sixty-five to 6.9 percent of those age eighty-five or older (Appendix Exhibit 1).14 Loss of Medicaid was also much more common among people who changed their state of residence, which may have been related
Exhibit 1 Loss Of Medicaid Benefits Among A 5 Percent Sample Of Medicare And Medicaid Dual Eligibles, 2009–11 Initial Medicaid benefit level, as of January 2009
Number of dual eligibles Number losing Medicaid benefits in next 36 monthsa Percent losing Medicaid benefits in next 36 monthsa Percent of those losing Medicaid benefits who regained them
Full benefits 292,242 45,493 15.6 51.3
Partial benefits 91,020 21,154 23.2 57.7
For those who lost Medicaid benefits: Number of times benefits were lost 1 2 3 or more Months of benefits lost 1–3 4–6 7–12 13–35
83.8% 11.1 5.0
87.1% 10.7 2.2
28.8% 13.5 15.2 42.5
33.5% 13.5 16.7 36.3
SOURCE Chronic Conditions Data Warehouse (see Note 10 in text). NOTES All dual eligibles in the sample had continuous Medicare Part A and Part B coverage during the three-year follow-up period. Beneficiaries residing in Texas were followed only through 2010, as explained in the text. Loss of Medicaid coverage in the month of death was not counted. Percentages may not sum to 100 because of rounding. aAmong full-benefit dual eligibles, loss of Medicaid benefits refers to loss of full-benefit status. Some of these beneficiaries might have retained partial benefits. Among partial-benefit dual eligibles, loss of Medicaid benefits refers to loss of Medicaid coverage altogether.
to differences in states’ eligibility criteria. Loss of Medicaid was significantly less frequent among those who incurred high Medicaid fee-for-service expenses per month in 2008: 7.4 percent of those incurring expenses of more than $1,000 per month subsequently lost Medicaid coverage, compared to 19.0 percent of those incurring expenses of $300 or less. This pattern may be attributable in part to incentives for providers such as nursing homes and intermediate care facilities to keep their patients enrolled in Medicaid. Compared to beneficiaries in fee-for-service arrangements, beneficiaries enrolled in D-SNPs were less likely to lose Medicaid coverage, and those enrolled in other Medicare Advantage plans were more likely to lose coverage. Loss of coverage tended to follow similar patterns among both enrollees with partial Medicaid benefits and those with full benefits (Appendix Exhibit 2).14 Several of the relationships between beneficiary characteristics and loss of Medicaid coverage were not as strong for partialbenefit enrollees as they were for full-benefit enrollees, however. Partial-benefit dual eligibles tended to incur much lower Medicaid expenses in 2008 than full-benefit enrollees did: 96 percent of partial-benefit enrollees in fee-for-service J anuary 201 4
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Medicaid Coverage incurred expenses of $300 or less per month, compared to 52 percent of full-benefit enrollees. This difference suggests that the impact of losing Medicaid coverage might be less for people with partial Medicaid benefits than for those with full benefits.15 Factors associated with the long-term (more than twelve months) loss of full Medicaid benefits were somewhat different from those associated with short-term loss (Appendix Exhibit 3).14 Younger ages for beneficiaries were more strongly associated with long-term loss than with shortterm loss, as was enrollment in a Medicare Advantage plan other than a D-SNP. Several characteristics were more strongly associated with the loss of full benefits over the short term than with that loss over the long term. The characteristics included higher Medicaid expenditures in 2008, incurring long-term care expenses under Medicaid, and Hispanic ethnicity. A similar pattern was observed for the loss of partial benefits (data not shown). Only 14.5 percent of dual eligibles who lost Medicaid coverage had an alternative source of health or long-term care insurance (Appendix Exhibit 4).14 Of those who lost coverage, 16.6 percent were enrolled in Medicare Advantage plans. These plans usually provide additional benefits, cover some Medicare cost sharing, or both, and they are often considered substitutes for Medicare supplemental insurance. Almost 70 percent of those who lost Medicaid coverage did not report having other insurance and were not in a Medicare Advantage plan.
Discussion
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◀ %
Of dual eligibles We found that 15.6 percent of fullbenefit dual eligibles lost their full-benefit status during our three-year follow-up period.
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We found that 15.6 percent of full-benefit dual eligibles lost their full-benefit status during our three-year follow-up period. This indicates that Medicaid enrollment is considerably more stable among dual eligibles than among non-Medicare populations.16,17 It is encouraging that some of the most vulnerable groups of dual eligibles tended to be at less risk of losing Medicaid coverage. For example, loss of coverage was relatively uncommon among heavy users of Medicaid services, who would be expected to suffer more than light users from losing Medicaid benefits. Loss of Medicaid coverage was also less common among people using long-term care services and among those age eighty-five or older. Dual eligibles who lose Medicaid coverage, especially those who do not regain it within a few months, might be at risk for problems with access to care. Loss of full Medicaid benefits results in loss of coverage for long-term care services, which are seldom covered by other sources of health insurance. Access to acute care services
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Most dual eligibles who lost Medicaid coverage did not have an alternative source of health insurance that could replace lost benefits.
might also be compromised through higher outof-pocket expenses once Medicaid support for Medicare cost sharing is lost. We found that most dual eligibles who lost Medicaid coverage did not have an alternative source of health insurance that could replace lost benefits, which is consistent with the findings of Stuart and Singhal.3 Other research has shown that Medicare beneficiaries without supplemental insurance have higher out-of-pocket expenses, fewer specialist visits, and lower use of preventive services than dual eligibles.18–20 Additional research is needed to examine the impacts of loss of Medicaid coverage on use, out-ofpocket expenses, access to care, and health outcomes. The loss of full Medicaid benefits among dual eligibles might present challenges for current initiatives that seek to achieve better clinical and financial integration of Medicare and Medicaid services. Such initiatives include the Program of All-Inclusive Care for the Elderly and Fully Integrated Dual Eligible Special Needs Plans, which coordinate the delivery of acute and long-term care services under risk-based financing. The initiatives also include the CMSsponsored Financial Alignment Initiative8 and state demonstration projects to support the design of integrated care programs for dual eligibles.9 Integrated care programs require detailed care planning; the exchange of information among caregivers; and the coordination of administrative functions among states, provider groups, and beneficiaries.21,22 The interruption or loss of Medicaid benefits might complicate ongoing care arrangements and produce gaps in health records that contain clinical and utilization data. It might also cause confusion and uncertainty among beneficiaries and could prompt disenrollments.
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As a vulnerable population requiring expensive care, dual eligibles will remain near the top of the health policy agenda for the foreseeable future.
Enrollees in D-SNPs are required to disenroll after a loss of Medicaid coverage, following a brief grace period. Our conversations with integrated health plan representatives have revealed that loss or interruption of Medicaid coverage can cause disruption of care patterns, administrative headaches, and increases in operational costs. Some of the lapses in Medicaid coverage are the result of miscommunications, beneficiaries’ misunderstandings, or language barriers. Integrated care plans sometimes work with their state Medicaid programs to identify upcoming renewal dates, maintain continuous Medicaid coverage for their enrollees where possible, and have coverage reinstated in some cases. As organizations design new models of integrated care for dual eligibles, they should anticipate losses of Medicaid coverage for some enrollees and should consider developing strategies for keeping Medicaid-eligible beneficiaries continuously enrolled. Many of the losses in Medicaid coverage we found in our sample of dual eligibles were temporary, with full-benefit status restored within a few months. Such losses might be related to failure on the part of the beneficiary to apply for renewal of coverage in a timely manner. Brief losses of coverage may complicate enrollment processing and increase administrative costs. This raises the question of whether some Medicaid renewal procedures could be simplified or Findings from the study reported here were presented at the AcademyHealth Annual Research Meeting in Baltimore, Maryland, June 25, 2013. The authors appreciate the assistance of Sha
changed to encourage more timely renewal applications. Procedures for renewal of Medicaid coverage are left to the states. We were unable to find any data sources providing detailed and comparable information on Medicaid renewal processes for dual eligibles across states. Enrollees in D-SNPs were less likely than other dual eligibles to lose Medicaid coverage. Because of their specialized focus on the dual eligible population, D-SNPs might have greater interest in maintaining continuity of Medicaid coverage among their enrollees and more incentives to do so, compared to other Medicare Advantage plans. The fact that enrollees in other plans were more likely to lose Medicaid coverage than DSNP enrollees raises the question of whether coordination between these plans and state agencies could be improved. The disabled population younger than age sixty-five was at relatively high risk for loss of both full and partial Medicaid benefits. Loss of Medicaid in this population could be related to beneficiaries’ attempts to reenter the workforce. States have the option to provide Medicaid eligibility to people with disabilities who have returned to work, and to establish more generous methods for treatment of earned income than for the treatment of other income. However, not all states do so. In states that do not provide such optional coverage, a return to work might result in the termination of Medicaid eligibility because of increased income. Medicare coverage continues for several years after a disabled beneficiary returns to work and his or her Social Security Disability Insurance benefits are terminated. Nonetheless, the potential loss of Medicaid coverage could serve as a disincentive to return to work.
Conclusion As a vulnerable population requiring expensive care, dual eligibles will remain near the top of the health policy agenda for the foreseeable future. Medicaid plays an essential role in giving this population access to long-term care and other health care services. An understanding of the dynamics of Medicaid retention and loss should help policy makers design better ways for the Medicare and Medicaid programs to work together to serve dual eligibles. ▪
Maresh and Susan Mathew in developing the database for this study. They thank Karyn Anderson for her helpful comments on a draft of the manuscript. The statements contained herein are
those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services.
January 2014
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Medicaid Coverage NOTES 1 Coughlin TA, Waidmann TA, Phadera L. Among dual eligibles, identifying the highest-cost individuals could help in crafting more targeted and effective responses. Health Aff (Millwood). 2012;31(5): 1083–91. 2 Young K, Garfield R, Musumeci M, Clemans-Cope L, Lawton E. Medicaid’s role for dual eligible beneficiaries [Internet]. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2013 Aug [cited 2013 Dec 2]. (Issue Brief). Available from http://kaiserfamilyfoundation.files .wordpress.com/2013/08/7846-04medicaids-role-for-dual-eligiblebeneficiaries.pdf 3 Stuart B, Singhal P. The stability of Medicaid coverage for low-income dually eligible Medicare beneficiaries. [Internet]. Menlo Park (CA): Kaiser Family Foundation; 2006 [cited 2013 Dec 2]. (Policy Brief). Available from: http://kaiserfamily foundation.files.wordpress.com/ 2013/01/7512.pdf 4 Centers for Medicare and Medicaid Services. Medicare-Medicaid dual enrollment from 2006 through 2011 [Internet]. Baltimore (MD): CMS; 2013 Feb [cited 2013 Dec 2]. (Data Analysis Brief). Available from: http://www.cms.gov/MedicareMedicaid-Coordination/Medicareand-Medicaid-Coordination/ Medicare-Medicaid-CoordinationOffice/Downloads/Dual_ Enrollment_2006-2011_Final_ Document.pdf 5 Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health care delivery system [Internet]. Washington (DC): MedPAC; 2013 Jun [cited 2013 Dec 6]. Chapter 6: Care needs for dual-eligible beneficiaries. Available from: http://www.medpac.gov/ documents/Jun13_EntireReport.pdf 6 Gold MR, Jacobson GA, Garfield RL. There is little experience and limited data to support policy making on integrated care for dual eligibles. Health Aff (Millwood). 2012;31(6): 1176–85. 7 Medicare Payment Advisory Commission. Report to the Congress: aligning incentives in Medicare [Internet]. Washington DC: MedPAC; 2010 Jun [cited 2013 Dec 2]. Chapter 5: Coordinating the care of dual-
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8
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eligible beneficiaries. Available from: http://www.medpac.gov/ documents/Jun10_EntireReport.pdf CMS.gov. Financial alignment initiative [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2013 Nov 26; cited 2013 Dec 2]. Available from: https://www.cms.gov/MedicareMedicaid-Coordination/Medicareand-Medicaid-Coordination/ Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupport StatesEffortsinCareCoordination .html CMS.gov. State design contract summaries [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2012 Jun 13; cited 2013 Dec 2]. Available from: http://www.cms .gov/Medicare-MedicaidCoordination/Medicare-andMedicaid-Coordination/MedicareMedicaid-Coordination-Office/State DesignContractSummaries.html Chronic Conditions Data Warehouse [home page on the Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2013 Dec 2]. Available from: http://www .ccwdata.org/index.htm Pope GC, Kautter J, Ellis RP, Ash AS, Ayanian JZ, Iezzoni LI, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev. 2004; 25(4):119–41. CMS.gov. Medicaid data sources— general information [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2013 Jun 5; cited 2013 Dec 2]. Available from: https://www.cms .gov/Research-Statistics-Data-andSystems/Computer-Data-andSystems/MedicaidDataSources GenInfo/index.html?redirect=/ MedicaidDataSourcesGenInfo/07_ MAXGeneralInformation.asp Adler GS. A profile of the Medicare Current Beneficiary Survey. Health Care Financ Rev. 1994;15(4):153–63. To access the Appendix, click on the Appendix link in the box to the right of the article online. Medicaid costs for partial-benefit dual eligibles represent only the Medicare beneficiary cost sharing (deductibles, coinsurance, copayments, and premiums) that Medic-
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aid pays for their Medicare benefits. For full-benefit dual eligibles, Medicaid costs represent primarily the cost of Medicaid-covered services (mostly nursing facility services and home and community-based services), which tend to be very expensive. Providers of long-term care services covered by Medicaid have strong incentives to make sure that their patients don’t lose Medicaid coverage because otherwise the providers would not be paid for their services. Sommers BD. Loss of health insurance among non-elderly adults in Medicaid. J Gen Intern Med. 2008; 24(1):1–7. Sommers BD. From Medicaid to uninsured: drop-out among children in public insurance programs. Health Serv Res. 2005;40(1):59–78. Goldman DP, Zissimopoulos JM. High out-of-pocket health care spending by the elderly. Health Aff (Millwood). 2003;22(3):194–202. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153–69. Greene J, Blustein J, Laflamme KA. Use of preventive care services, beneficiary characteristics, and Medicare HMO performance. Health Care Financ Rev. 2001;22(4):141–53. Milligan CJ Jr., Woodcock CH. Medicare Advantage Special Needs Plans for dual eligibles: a primer [Internet]. New York (NY): Commonwealth Fund; 2008 Feb [cited 2013 Dec 3]. (Issue Brief). Available from: http://www.commonwealth fund.org/~/media/Files/ Publications/Issue%20Brief/2008/ Feb/Medicare%20Advantage%20 Special%20Needs%20Plans%20for %20Dual%20Eligibles%20%20A %20Primer/Milligan_Medicare Advspecneedsprimer_1108_ib%20 pdf.pdf Thorpe KE. Estimated federal savings associated with care coordination models for Medicare-Medicaid dual eligibles [Internet].Washington (DC): America’s Health Insurance Plans; 2011 Sep [cited 2013 Dec 3]. Available from: http://www.ahip coverage.com/wp-content/uploads/ 2011/09/Dual-Eligible-StudySeptember-2011.pdf
The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/33/1/147.full.html
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2014 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Medicaid Coverage By Gerald F. Riley, Lirong Zhao, and Negussie Tilahun 10.1377/hlthaff.2013.0396 HEALTH AFFAIRS 33, NO. 1 (2014): 147–152 ©2014 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Understanding Factors Associated With Loss Of Medicaid Coverage Among Dual Eligibles Can Help Identify Vulnerable Enrollees For people who receive both Medicare and Medicaid benefits (dual-eligible beneficiaries), the loss of Medicaid coverage may lead to problems with care coordination, higher out-of-pocket expenses, or reduced access to services. Using administrative data, we followed 292,242 full-benefit and 91,020 partial-benefit dual eligibles from January 2009 through December 2011. Among those with full Medicaid benefits, 15.6 percent lost Medicaid coverage at least once, with more frequent losses among younger beneficiaries. Many of these losses lasted only one to three months and were followed by reinstatement. Loss of Medicaid coverage was more common (23.2 percent) among enrollees with partial Medicaid benefits. Medicare Current Beneficiary Survey data indicate that most dual eligibles who lost Medicaid coverage had no other source of supplemental insurance. Medicaid coverage is relatively stable among dual eligibles. However, some lose Medicaid for several months or more, putting them at risk for poor outcomes and potentially complicating their care, especially when it needs to be integrated under the two programs. ABSTRACT
P
eople receiving both Medicare and Medicaid benefits (known as dualeligible beneficiaries) have been the subject of extensive policy interest because of their poor health, complex care needs, and high costs.1 In addition, this population is characterized by low incomes and a lack of private health insurance and thus is vulnerable to problems with access to care.2,3 Most dual eligibles have full Medicaid benefits that include coverage of long-term care services and most Medicare cost-sharing and premium expenses. Twenty-seven percent have partial benefits, receiving Medicaid support only for Medicare cost sharing, premiums, or both.4 Per capita spending for dual eligibles (with either full or partial benefits) in 2009 was estimated to be $15,743 and $13,564 under Medicare and Medicaid, respectively—much higher than spending for other Medicare beneficiaries.5
Gerald F. Riley (gerald.riley@ cms.hhs.gov) is a social science research analyst at the Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, in Baltimore, Maryland. Lirong Zhao is a quantitative research analyst at the Center for Medicare and Medicaid Innovation. Negussie Tilahun is a social science research analyst at the Center for Medicare and Medicaid Innovation.
Historically, health care for dual eligibles has suffered from a lack of coordination on several levels. A lack of clinical integration of acute and long-term care has led to inefficiencies and lower quality of care.6 And a lack of financial integration of payments under Medicare and Medicaid has produced conflicting program incentives and cost shifting that might raise overall costs.7 Differences in Medicare and Medicaid administrative structures have created barriers to improvement. Accordingly, coordination of care under the two programs has been the focus of several special policy initiatives, such as Dual Eligible Special Needs Plans (D-SNPs) and the Program of All-Inclusive Care for the Elderly. More recently, the Centers for Medicare and Medicaid Services (CMS) has begun testing payment and service delivery models that integrate care and funding under Medicare and Medicaid.8,9 J a n u a ry 2 0 1 4
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Medicaid Coverage Medicare enrollees seldom leave the program. However, Medicaid coverage can be more volatile because of beneficiaries’ fluctuations in income, changes in eligibility status, or failure to apply for renewal of Medicaid eligibility in a timely manner. Bruce Stuart and Puneet Singhal3 reported a rate of Medicaid disenrollment among dual eligibles of 5.4 percent per year. Loss of Medicaid coverage might undermine integrated programs of care for dual eligibles and thwart efforts to improve the efficiency of care delivery for them. Their access to care might also be compromised by their loss of coverage for long-term care services and increased liability associated with Medicare cost sharing and premiums, following the loss of Medicaid. This study used Medicare and Medicaid administrative data to examine several issues related to loss of Medicaid coverage in 2009–11 among dual eligibles with full or partial benefits. The following research questions were addressed: What percentage of dual eligibles lose Medicaid coverage, and for how long? What are the risk factors for such loss? How frequently is Medicaid coverage regained, and how much time elapses between loss of coverage and reinstatement? Do dual eligibles who lose Medicaid coverage have other supplemental insurance?
Study Data And Methods Data Our primary data source was the annual Master Beneficiary Summary File, which is part of the Medicare Chronic Conditions Data Warehouse10 and contains data on beneficiaries’ demographic characteristics and enrollment in Medicare, Medicare Advantage, and Medicaid. From the 2009 Master Beneficiary Summary File, we identified a cohort consisting of a 5 percent random sample of Medicare beneficiaries who resided in the United States, were entitled to Medicare Parts A and B, and were eligible for full or partial Medicaid benefits in January 2009. These 2009 records were linked to Master Beneficiary Summary File records for 2010–11 to permit follow-up through December 2011. Hierarchical Condition Category risk scores, which predict Medicare costs based on beneficiaries’ diagnoses and demographic characteristics, were obtained from internal CMS files as a proxy for health status.11 Medicaid Analytic Extract personal summary files for 2008 were also used to obtain the basis of Medicaid eligibility and to calculate monthly Medicaid fee-forservice costs prior to loss of coverage.12 These files were not available for the years after 2008 at the time of this study. The final sample size was 383,262 dual eligibles. Analyses The key outcome variable was loss 148
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of Medicaid coverage between January 2009 and the earliest occurrence of death, loss of Medicare Part A or B coverage, or December 2011. For fullbenefit dual eligibles, any loss of full Medicaid benefits was counted as a loss of Medicaid coverage, including a change from full-benefit to partial-benefit status. Exploratory analyses revealed two anomalies in the data set. First, a very high proportion of dual eligibles first lost Medicaid coverage in the month of death in several states in certain years. These situations were not counted as losses of Medicaid coverage in the analysis. Second, an implausibly high proportion of dual eligibles in Texas lost Medicaid coverage in 2011, usually for one month. We therefore followed Texas residents through 2010 only. Descriptive statistics and logistic regression were used to determine how often Medicaid coverage was lost and for how long, whether it was regained, and what the risk factors were for losing coverage. All analyses were stratified by level of Medicaid benefits (full or partial). We did this because of the differences in the two populations (income eligibility criteria are stricter for those with full benefits, so they tend to have lower incomes) and the different implications for the beneficiary of losing full or partial Medicaid benefits. We used data from the Medicare Current Beneficiary Survey to examine whether dual eligibles had any other sources of health insurance besides Medicare following loss of Medicaid coverage. This survey is a longitudinal, multipurpose survey of a nationally representative sample of the Medicare population.13 Respondents are asked about the source of any private or public health insurance they have besides Medicare and the type of that insurance, such as general, dental, or long-term care. Each respondent participates in up to four fall rounds of the survey; each round is summarized in annual Access to Care Files. We pooled data from these files for 2006–10. For the years 2006–09 we identified respondents who had full Medicaid benefits or partial benefits for Medicare cost sharing and who were not in their last year of Medicare Current Beneficiary Survey participation.We excluded partial-benefit enrollees who received Medicaid support for Medicare premiums only. We then identified which of the remaining respondents were without full Medicaid benefits or partial benefits for Medicare cost sharing in the subsequent fall round of the survey; there were 345. We calculated the percentage of beneficiaries in this group who reported having general private or public health insurance or long-term care insurance in the subsequent round. If respondents reported
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receiving health care services from the Department of Veterans Affairs at any time in the calendar year of the subsequent round (through the Medicare Current Beneficiary Survey Cost and Use Files), we counted that as the equivalent of having health insurance. All percentages were calculated using the survey’s longitudinal weights. Limitations Three limitations to our study should be kept in mind. First, we were unable to determine why dual eligibles lost their Medicaid coverage. Possible reasons include an increase in income or assets, failure to apply for renewal in a timely manner, changes in eligibility status, and improvements in health or a return to work for people under age sixty-five.We expect that different reasons for the loss of Medicaid coverage would provoke different policy responses. Second, we could not directly measure the impact of the loss of Medicaid coverage on health outcomes or access to care. And third, our findings were subject to the accuracy of Medicare administrative records and data reported by the various state Medicaid programs.
Study Results During the three-year follow-up period, 45,493 people with full benefits lost Medicaid coverage at least once (Exhibit 1). Multiplying the number from the 5 percent sample by 20 suggests that more than 900,000 dual eligibles lost full-benefit status in the study period. About half of those in the sample who lost full Medicaid benefits regained them, but more than 16 percent of those who lost full benefits did so more than once (Exhibit 1). Approximately 37 percent of all losses involved a transition from full-benefit to partial-benefit status (data not shown). Of those who lost full Medicaid benefits, 28.8 percent lost them for only one to three months, but 42.5 percent lost them for more than twelve months (Exhibit 1). Among those with partial Medicaid benefits, 23.2 percent lost Medicaid coverage, with 57.7 percent of them regaining coverage (Exhibit 1). Roughly one-third of these coverage losses lasted one to three months, and slightly more than one-third were for more than twelve months. Among dual eligibles with full Medicaid benefits, the probability of losing Medicaid coverage declined in higher age groups, from 21.3 percent for those under age sixty-five to 6.9 percent of those age eighty-five or older (Appendix Exhibit 1).14 Loss of Medicaid was also much more common among people who changed their state of residence, which may have been related
Exhibit 1 Loss Of Medicaid Benefits Among A 5 Percent Sample Of Medicare And Medicaid Dual Eligibles, 2009–11 Initial Medicaid benefit level, as of January 2009
Number of dual eligibles Number losing Medicaid benefits in next 36 monthsa Percent losing Medicaid benefits in next 36 monthsa Percent of those losing Medicaid benefits who regained them
Full benefits 292,242 45,493 15.6 51.3
Partial benefits 91,020 21,154 23.2 57.7
For those who lost Medicaid benefits: Number of times benefits were lost 1 2 3 or more Months of benefits lost 1–3 4–6 7–12 13–35
83.8% 11.1 5.0
87.1% 10.7 2.2
28.8% 13.5 15.2 42.5
33.5% 13.5 16.7 36.3
SOURCE Chronic Conditions Data Warehouse (see Note 10 in text). NOTES All dual eligibles in the sample had continuous Medicare Part A and Part B coverage during the three-year follow-up period. Beneficiaries residing in Texas were followed only through 2010, as explained in the text. Loss of Medicaid coverage in the month of death was not counted. Percentages may not sum to 100 because of rounding. aAmong full-benefit dual eligibles, loss of Medicaid benefits refers to loss of full-benefit status. Some of these beneficiaries might have retained partial benefits. Among partial-benefit dual eligibles, loss of Medicaid benefits refers to loss of Medicaid coverage altogether.
to differences in states’ eligibility criteria. Loss of Medicaid was significantly less frequent among those who incurred high Medicaid fee-for-service expenses per month in 2008: 7.4 percent of those incurring expenses of more than $1,000 per month subsequently lost Medicaid coverage, compared to 19.0 percent of those incurring expenses of $300 or less. This pattern may be attributable in part to incentives for providers such as nursing homes and intermediate care facilities to keep their patients enrolled in Medicaid. Compared to beneficiaries in fee-for-service arrangements, beneficiaries enrolled in D-SNPs were less likely to lose Medicaid coverage, and those enrolled in other Medicare Advantage plans were more likely to lose coverage. Loss of coverage tended to follow similar patterns among both enrollees with partial Medicaid benefits and those with full benefits (Appendix Exhibit 2).14 Several of the relationships between beneficiary characteristics and loss of Medicaid coverage were not as strong for partialbenefit enrollees as they were for full-benefit enrollees, however. Partial-benefit dual eligibles tended to incur much lower Medicaid expenses in 2008 than full-benefit enrollees did: 96 percent of partial-benefit enrollees in fee-for-service J anuary 201 4
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Medicaid Coverage incurred expenses of $300 or less per month, compared to 52 percent of full-benefit enrollees. This difference suggests that the impact of losing Medicaid coverage might be less for people with partial Medicaid benefits than for those with full benefits.15 Factors associated with the long-term (more than twelve months) loss of full Medicaid benefits were somewhat different from those associated with short-term loss (Appendix Exhibit 3).14 Younger ages for beneficiaries were more strongly associated with long-term loss than with shortterm loss, as was enrollment in a Medicare Advantage plan other than a D-SNP. Several characteristics were more strongly associated with the loss of full benefits over the short term than with that loss over the long term. The characteristics included higher Medicaid expenditures in 2008, incurring long-term care expenses under Medicaid, and Hispanic ethnicity. A similar pattern was observed for the loss of partial benefits (data not shown). Only 14.5 percent of dual eligibles who lost Medicaid coverage had an alternative source of health or long-term care insurance (Appendix Exhibit 4).14 Of those who lost coverage, 16.6 percent were enrolled in Medicare Advantage plans. These plans usually provide additional benefits, cover some Medicare cost sharing, or both, and they are often considered substitutes for Medicare supplemental insurance. Almost 70 percent of those who lost Medicaid coverage did not report having other insurance and were not in a Medicare Advantage plan.
Discussion
15.6
◀ %
Of dual eligibles We found that 15.6 percent of fullbenefit dual eligibles lost their full-benefit status during our three-year follow-up period.
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We found that 15.6 percent of full-benefit dual eligibles lost their full-benefit status during our three-year follow-up period. This indicates that Medicaid enrollment is considerably more stable among dual eligibles than among non-Medicare populations.16,17 It is encouraging that some of the most vulnerable groups of dual eligibles tended to be at less risk of losing Medicaid coverage. For example, loss of coverage was relatively uncommon among heavy users of Medicaid services, who would be expected to suffer more than light users from losing Medicaid benefits. Loss of Medicaid coverage was also less common among people using long-term care services and among those age eighty-five or older. Dual eligibles who lose Medicaid coverage, especially those who do not regain it within a few months, might be at risk for problems with access to care. Loss of full Medicaid benefits results in loss of coverage for long-term care services, which are seldom covered by other sources of health insurance. Access to acute care services
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Most dual eligibles who lost Medicaid coverage did not have an alternative source of health insurance that could replace lost benefits.
might also be compromised through higher outof-pocket expenses once Medicaid support for Medicare cost sharing is lost. We found that most dual eligibles who lost Medicaid coverage did not have an alternative source of health insurance that could replace lost benefits, which is consistent with the findings of Stuart and Singhal.3 Other research has shown that Medicare beneficiaries without supplemental insurance have higher out-of-pocket expenses, fewer specialist visits, and lower use of preventive services than dual eligibles.18–20 Additional research is needed to examine the impacts of loss of Medicaid coverage on use, out-ofpocket expenses, access to care, and health outcomes. The loss of full Medicaid benefits among dual eligibles might present challenges for current initiatives that seek to achieve better clinical and financial integration of Medicare and Medicaid services. Such initiatives include the Program of All-Inclusive Care for the Elderly and Fully Integrated Dual Eligible Special Needs Plans, which coordinate the delivery of acute and long-term care services under risk-based financing. The initiatives also include the CMSsponsored Financial Alignment Initiative8 and state demonstration projects to support the design of integrated care programs for dual eligibles.9 Integrated care programs require detailed care planning; the exchange of information among caregivers; and the coordination of administrative functions among states, provider groups, and beneficiaries.21,22 The interruption or loss of Medicaid benefits might complicate ongoing care arrangements and produce gaps in health records that contain clinical and utilization data. It might also cause confusion and uncertainty among beneficiaries and could prompt disenrollments.
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As a vulnerable population requiring expensive care, dual eligibles will remain near the top of the health policy agenda for the foreseeable future.
Enrollees in D-SNPs are required to disenroll after a loss of Medicaid coverage, following a brief grace period. Our conversations with integrated health plan representatives have revealed that loss or interruption of Medicaid coverage can cause disruption of care patterns, administrative headaches, and increases in operational costs. Some of the lapses in Medicaid coverage are the result of miscommunications, beneficiaries’ misunderstandings, or language barriers. Integrated care plans sometimes work with their state Medicaid programs to identify upcoming renewal dates, maintain continuous Medicaid coverage for their enrollees where possible, and have coverage reinstated in some cases. As organizations design new models of integrated care for dual eligibles, they should anticipate losses of Medicaid coverage for some enrollees and should consider developing strategies for keeping Medicaid-eligible beneficiaries continuously enrolled. Many of the losses in Medicaid coverage we found in our sample of dual eligibles were temporary, with full-benefit status restored within a few months. Such losses might be related to failure on the part of the beneficiary to apply for renewal of coverage in a timely manner. Brief losses of coverage may complicate enrollment processing and increase administrative costs. This raises the question of whether some Medicaid renewal procedures could be simplified or Findings from the study reported here were presented at the AcademyHealth Annual Research Meeting in Baltimore, Maryland, June 25, 2013. The authors appreciate the assistance of Sha
changed to encourage more timely renewal applications. Procedures for renewal of Medicaid coverage are left to the states. We were unable to find any data sources providing detailed and comparable information on Medicaid renewal processes for dual eligibles across states. Enrollees in D-SNPs were less likely than other dual eligibles to lose Medicaid coverage. Because of their specialized focus on the dual eligible population, D-SNPs might have greater interest in maintaining continuity of Medicaid coverage among their enrollees and more incentives to do so, compared to other Medicare Advantage plans. The fact that enrollees in other plans were more likely to lose Medicaid coverage than DSNP enrollees raises the question of whether coordination between these plans and state agencies could be improved. The disabled population younger than age sixty-five was at relatively high risk for loss of both full and partial Medicaid benefits. Loss of Medicaid in this population could be related to beneficiaries’ attempts to reenter the workforce. States have the option to provide Medicaid eligibility to people with disabilities who have returned to work, and to establish more generous methods for treatment of earned income than for the treatment of other income. However, not all states do so. In states that do not provide such optional coverage, a return to work might result in the termination of Medicaid eligibility because of increased income. Medicare coverage continues for several years after a disabled beneficiary returns to work and his or her Social Security Disability Insurance benefits are terminated. Nonetheless, the potential loss of Medicaid coverage could serve as a disincentive to return to work.
Conclusion As a vulnerable population requiring expensive care, dual eligibles will remain near the top of the health policy agenda for the foreseeable future. Medicaid plays an essential role in giving this population access to long-term care and other health care services. An understanding of the dynamics of Medicaid retention and loss should help policy makers design better ways for the Medicare and Medicaid programs to work together to serve dual eligibles. ▪
Maresh and Susan Mathew in developing the database for this study. They thank Karyn Anderson for her helpful comments on a draft of the manuscript. The statements contained herein are
those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare and Medicaid Services.
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Medicaid Coverage NOTES 1 Coughlin TA, Waidmann TA, Phadera L. Among dual eligibles, identifying the highest-cost individuals could help in crafting more targeted and effective responses. Health Aff (Millwood). 2012;31(5): 1083–91. 2 Young K, Garfield R, Musumeci M, Clemans-Cope L, Lawton E. Medicaid’s role for dual eligible beneficiaries [Internet]. Washington (DC): Kaiser Commission on Medicaid and the Uninsured; 2013 Aug [cited 2013 Dec 2]. (Issue Brief). Available from http://kaiserfamilyfoundation.files .wordpress.com/2013/08/7846-04medicaids-role-for-dual-eligiblebeneficiaries.pdf 3 Stuart B, Singhal P. The stability of Medicaid coverage for low-income dually eligible Medicare beneficiaries. [Internet]. Menlo Park (CA): Kaiser Family Foundation; 2006 [cited 2013 Dec 2]. (Policy Brief). Available from: http://kaiserfamily foundation.files.wordpress.com/ 2013/01/7512.pdf 4 Centers for Medicare and Medicaid Services. Medicare-Medicaid dual enrollment from 2006 through 2011 [Internet]. Baltimore (MD): CMS; 2013 Feb [cited 2013 Dec 2]. (Data Analysis Brief). Available from: http://www.cms.gov/MedicareMedicaid-Coordination/Medicareand-Medicaid-Coordination/ Medicare-Medicaid-CoordinationOffice/Downloads/Dual_ Enrollment_2006-2011_Final_ Document.pdf 5 Medicare Payment Advisory Commission. Report to the Congress: Medicare and the health care delivery system [Internet]. Washington (DC): MedPAC; 2013 Jun [cited 2013 Dec 6]. Chapter 6: Care needs for dual-eligible beneficiaries. Available from: http://www.medpac.gov/ documents/Jun13_EntireReport.pdf 6 Gold MR, Jacobson GA, Garfield RL. There is little experience and limited data to support policy making on integrated care for dual eligibles. Health Aff (Millwood). 2012;31(6): 1176–85. 7 Medicare Payment Advisory Commission. Report to the Congress: aligning incentives in Medicare [Internet]. Washington DC: MedPAC; 2010 Jun [cited 2013 Dec 2]. Chapter 5: Coordinating the care of dual-
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eligible beneficiaries. Available from: http://www.medpac.gov/ documents/Jun10_EntireReport.pdf CMS.gov. Financial alignment initiative [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2013 Nov 26; cited 2013 Dec 2]. Available from: https://www.cms.gov/MedicareMedicaid-Coordination/Medicareand-Medicaid-Coordination/ Medicare-Medicaid-CoordinationOffice/FinancialModelstoSupport StatesEffortsinCareCoordination .html CMS.gov. State design contract summaries [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2012 Jun 13; cited 2013 Dec 2]. Available from: http://www.cms .gov/Medicare-MedicaidCoordination/Medicare-andMedicaid-Coordination/MedicareMedicaid-Coordination-Office/State DesignContractSummaries.html Chronic Conditions Data Warehouse [home page on the Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [cited 2013 Dec 2]. Available from: http://www .ccwdata.org/index.htm Pope GC, Kautter J, Ellis RP, Ash AS, Ayanian JZ, Iezzoni LI, et al. Risk adjustment of Medicare capitation payments using the CMS-HCC model. Health Care Financ Rev. 2004; 25(4):119–41. CMS.gov. Medicaid data sources— general information [Internet]. Baltimore (MD): Centers for Medicare and Medicaid Services; [last modified 2013 Jun 5; cited 2013 Dec 2]. Available from: https://www.cms .gov/Research-Statistics-Data-andSystems/Computer-Data-andSystems/MedicaidDataSources GenInfo/index.html?redirect=/ MedicaidDataSourcesGenInfo/07_ MAXGeneralInformation.asp Adler GS. A profile of the Medicare Current Beneficiary Survey. Health Care Financ Rev. 1994;15(4):153–63. To access the Appendix, click on the Appendix link in the box to the right of the article online. Medicaid costs for partial-benefit dual eligibles represent only the Medicare beneficiary cost sharing (deductibles, coinsurance, copayments, and premiums) that Medic-
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aid pays for their Medicare benefits. For full-benefit dual eligibles, Medicaid costs represent primarily the cost of Medicaid-covered services (mostly nursing facility services and home and community-based services), which tend to be very expensive. Providers of long-term care services covered by Medicaid have strong incentives to make sure that their patients don’t lose Medicaid coverage because otherwise the providers would not be paid for their services. Sommers BD. Loss of health insurance among non-elderly adults in Medicaid. J Gen Intern Med. 2008; 24(1):1–7. Sommers BD. From Medicaid to uninsured: drop-out among children in public insurance programs. Health Serv Res. 2005;40(1):59–78. Goldman DP, Zissimopoulos JM. High out-of-pocket health care spending by the elderly. Health Aff (Millwood). 2003;22(3):194–202. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9(2):153–69. Greene J, Blustein J, Laflamme KA. Use of preventive care services, beneficiary characteristics, and Medicare HMO performance. Health Care Financ Rev. 2001;22(4):141–53. Milligan CJ Jr., Woodcock CH. Medicare Advantage Special Needs Plans for dual eligibles: a primer [Internet]. New York (NY): Commonwealth Fund; 2008 Feb [cited 2013 Dec 3]. (Issue Brief). Available from: http://www.commonwealth fund.org/~/media/Files/ Publications/Issue%20Brief/2008/ Feb/Medicare%20Advantage%20 Special%20Needs%20Plans%20for %20Dual%20Eligibles%20%20A %20Primer/Milligan_Medicare Advspecneedsprimer_1108_ib%20 pdf.pdf Thorpe KE. Estimated federal savings associated with care coordination models for Medicare-Medicaid dual eligibles [Internet].Washington (DC): America’s Health Insurance Plans; 2011 Sep [cited 2013 Dec 3]. Available from: http://www.ahip coverage.com/wp-content/uploads/ 2011/09/Dual-Eligible-StudySeptember-2011.pdf
