In 2020, about 12 million people were eligible for both Medicare and Medicaid. Known as dually eligible beneficiaries, these individuals all have low income and, because of advanced age or disability, have more need of health services and long-term care than Medicare-only beneficiaries. But different benefits, delivery systems, providers, and appeals systems across the two programs can make it extraordinarily difficult to navigate the two disparate systems of coverage.
To improve care outcomes and reduce spending for dually eligible beneficiaries, federal and state policymakers have created a variety of care models to better coordinate and integrate Medicare and Medicaid benefits. Of the major integrated care models, the most popular are Dual-Eligible Special Needs Plans (D-SNPs), a type of Medicare Advantage plan that limits enrollment to dually eligible beneficiaries and is required to coordinate the delivery of Medicaid benefits. Yet voluntary disenrollment from Medicare Advantage plans with a majority of D-SNP enrollees is more common than from plans that enroll Medicare-only beneficiaries.
Policymakers are now exploring ways to increase enrollment by dually eligible beneficiaries in the most integrated care models, particularly D-SNPs that are fully integrated with Medicaid. To achieve this goal, it is important to know what makes beneficiaries stay or leave. Do higher disenrollment rates from these plans signal quality problems or poor coordination of Medicaid services? Or do they stem from other causes?
To find out why dually eligible individuals leave Medicare Advantage plans, Mathematica conducted a study supported by Arnold Ventures on disenrollment patterns in plans with a majority (70 percent or more) D-SNP members. The plans in the study sample varied in the degree to which they coordinated or covered Medicaid benefits, such as long-term services and supports and behavioral health services. We recently released findings from our analysis in a full report and issue brief.
We first tested whether voluntary disenrollment from the plans in our study sample was associated with performance on measures of care quality and beneficiary experience. Three of the nine measures we examined were associated with lower rates of disenrollment. For example, higher member ratings of the health plan and higher flu vaccination rates were both associated with fewer members leaving the plan. Conversely, more member complaints about the health plan was associated with more members leaving. But the other six measures, which addressed the quality of clinical care, either had an association in an unexpected direction or were not associated with disenrollment.
To test the commonly held belief that greater coordination of Medicare and Medicaid benefits improves enrollee experience, we also examined the association between level of Medicaid integration and voluntary disenrollment. We did not find a statistically significant association between more integrated plans and less voluntary disenrollment. In sensitivity tests, we found associations with disenrollment rates for plans of different sizes and levels of integration, but in opposite directions. This suggests that something other than integration level explains the results.
Many Factors Induce Beneficiaries to Stay or Leave
Through interviews with state Medicaid officials and health plan executives, we learned how myriad factors affect dually eligible beneficiaries’ decisions to remain in or leave Medicare Advantage D-SNPs.
- State policies and programs. State Medicaid contracts with the most integrated D-SNPs and requirements that promote aligned enrollment with Medicaid managed care plans make it easier to coordinate care, which respondents said help to retain members with greater care needs.
- Local market competition. Highly competitive markets with numerous Medicare Advantage plans in states such as Florida and Texas tend to see more disenrollment from Medicare Advantage D-SNPs, compared to those located in states with less competition. Medicare Advantage plans compete with one another over the generosity of supplemental benefits and lower cost sharing, which can contribute to disenrollment from D-SNPs—particularly among partial-benefit duals who incur higher out-of-pocket costs than full-benefit duals.
- Changes in beneficiaries’ circumstances. A change in health or functional ability, or a shift from full- to partial-benefit dual status or vice versa, can spur D-SNP members to switch to another Medicare Advantage plan or back to traditional Medicare.
Dually eligible beneficiaries have more D-SNPs to choose from than ever before. The number of D-SNPs grew from 400 in 2018 to nearly 600 in 2021. Starting January 1, 2021, D-SNPs must meet new requirements designed to further integrate Medicare and Medicaid benefits. But in many states, contracts with D-SNPs do not require them to be fully integrated with Medicaid. D-SNPs also continue to face stiff competition from Medicare Advantage plans that are not integrated with Medicaid at all.
Based on the study findings, policymakers could make a number of changes to increase enrollment and retention of dually eligible individuals in the most integrated care plans. For example, they could:
- Reduce the impact of beneficiary cost sharing on disenrollment among full-benefit duals through stronger enforcement of, and education about, the federal prohibition on balance billing
- Award higher Medicare Advantage star ratings based on (1) plans’ ability to retain members and (2) measures that directly reflect member satisfaction (CMS intends to assign greater weight to these measures in the star ratings to be released in 2023)
- Prohibit regular Medicare Advantage plans from enrolling full benefit dually eligible individuals in areas where these beneficiaries have a choice of D-SNPs and other types of integrated plans, along with traditional Medicare fee-for-service
These and other policy changes described in the report can help ensure that voluntary disenrollment rates convey more meaningful information to federal and state officials, health plans, and dually eligible individuals about consumers’ satisfaction with Medicare Advantage D-SNPs.