Medicare dual eligible

Recently, Congress and CMS have placed greater emphasis on the coordination and integration of Medicare and Medicaid benefits for dual-eligible beneficiaries.

More recently, the Affordable Care Act (ACA) established a type of D-SNP, referred to as a Fully Integrated Dual Eligible (FIDE) SNP, which—unlike other D-SNPs—is designed to integrate program benefits for dual-eligible beneficiaries through a single managed care organization, although payment is generally provided separately by each program.

These two systems of care do not "talk to each other" systematically, so one physician that bills primarily through Medicare may not be familiar with benefits that are available through Medicaid.

[2] One proposed reason for this significant cost would be that many Medicaid programs, prior to the 2010 passage of the Affordable Care Act (ACA) used a fee-for-service model.

[9] In order to resolve these pain points, the ACA includes provisions that specifically address the coverage and care of duals.

[8] These offices focus on both monetary expenses as well as care innovation and quality for dual eligible beneficiaries.

Furthermore, the FIDE-SNPs that reported potential Medicare savings generally did not demonstrate lower costs than other D-SNPs in the same geographic areas.

While operating specialized plans and integrating benefits could lead to improved care, GAO's results suggest that these conditions have not demonstrated a reduction in dual-eligible beneficiaries' Medicare spending compared with Medicare spending in settings without integrated benefits.

Because the GAO study also found that the average number of costly Medicare services increases as the number of chronic and mental health conditions increase, it is possible that savings were not demonstrated because the population being served by FIDE-SNPs is too large to be cost-effective and major complications were averted for relatively few beneficiaries.

A further study by the same group of researchers found that despite the above physicians' views on access to healthcare among dual-eligibles, there were no statistically significant changes in pharmaceutical utilization or out-of-pocket expenditures in the 18 months after Medicare Part D implementation.