A primer on dual-eligible Californians: how people enrolled in both Medicare and Medi-Cal receive their care
- Collection:
- Health Policy and Services Research
- Author(s):
- Christ, Amber, author Burke, Georgia, author
- Contributor(s):
- California HealthCare Foundation, issuing body.
- Publication:
- [Oakland, California] : California Health Care Foundation, September 2020
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Dual MEDICAID MEDICARE Eligibility California United States
- Genre(s):
- Technical Report
- Abstract:
- California is home to nearly 20% of the country's older adults with low incomes and persons with disabilities who receive health care coverage from both Medicare and Medicaid. These 1.4 million Californians enrolled in Medicare and full-benefit Medi-Cal, California's Medicaid program, are known as dual-eligible enrollees. Restructuring administration of the delivery of health care benefits to this population is a priority for the Medi-Cal program. On average, dual-eligible enrollees constitute the highest-need, highest-cost segment of both the Medicare and Medi-Cal enrollee populations, with wide variation in need and cost within the population. Because these enrollees receive health care services through two programs, each with its own complex rules, accessing services and integrating care present unique challenges. Further, variations in program design, particularly on the Medi-Cal side, exist in different regions in California, complicating both delivery of services and state oversight functions. For enrollees, the result is that the systems they currently navigate and the options available to them depend largely on where they live and what services they need to access. In 2019, California's Department of Health Care Services (DHCS) announced a Medi-Cal restructuring initiative, Advancing and Innovating Medi-Cal (CalAIM). The initiative included proposals to develop program options that would integrate Medicare and Medi-Cal benefits available throughout the state, to mandate enrollment in Medi-Cal managed care for virtually all dual-eligible enrollees, and to realign a number of programs affecting the dual-eligible population. Because of the COVID-19 emergency, the CalAIM proposal has been put on hold for a minimum of 12 months. COVID-19 has had a disproportionate and devastating impact on the dual-eligible population. Initial data show that dual-eligible enrollees, for example, are more than four times more likely to be diagnosed with and hospitalized for COVID-19 compared with Medicare-only enrollees. When the state reexamines ways to reform how dual-eligible enrollees receive their care, learnings from the pandemic will be a critical element in that review. This paper seeks to assist policymakers and stakeholders when the state revisits and reassesses the CalAIM proposal by providing a comprehensive overview of the characteristics of the dual-eligible enrollee population in California and the current structures for administration and delivery of services. The goal of the paper is to help stakeholders understand the complexities of service delivery for dual-eligible enrollees and to assess the impact of proposed changes on how enrollees can access care under both Medicare and Medi-Cal. The paper identifies transition challenges and areas of complexity and suggests measures to protect enrollees from interruptions in care during any change. Specifically, the paper presents information on the current landscape of delivery of benefits for dual-eligible enrollees, including variations within the state. The following topics are discussed: (1) Characteristics of California's dual-eligible enrollees. The paper reviews demographic and health data on California's dual-eligible population compared with enrollees who qualify only for the Medicare benefit, as well as data on dual-eligible enrollees' cost to both programs. (2) Current benefit delivery structures for dual-eligible enrollees. The paper describes the different ways dual-eligible enrollee groups currently receive both Medicare and Medi-Cal services, including more granular data, where available, showing the numbers enrolled in various models. This section looks at the complex array of enrollment options for both Medicare and Medi-Cal that vary depending on which services the enrollee needs and where an enrollee resides. This section also identifies benefits available in Medi-Cal managed care and those that are carved out of the managed care model. (3) Policy and operational imperatives to reduce disruption to dual-eligible enrollees in transitions. This discussion draws from the experience of the transition of dual-eligible enrollees in California's Coordinated Care Initiative to identify areas of particular importance for ensuring enrollee protection and access to care during transitions to new systems.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (30 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101771907 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101771907