Insights

For those with both Medicare and Medicaid coverage (“dually eligible individuals”), Medicare health care coverage options are most common: fee-for-service (FFS), a Dual Eligible Special Needs Plan (D-SNP), or a non–D-SNP Medicare Advantage (MA) plan. (Non-D-SNP MA plans include special needs plans catering to people with chronic conditions [C-SNP plans] and people who are institutionalized [I-SNP plans], as well as non–SNP MA plans. Among dually eligible non–D-SNP MA enrollees, fewer than 10% are in a C-SNP or I-SNP plan. This analysis excludes people with dual eligible coverage who are in I-SNPs. Because all people with dual-eligible coverage received Part D (PD) coverage, here both MA and FFS coverage always includes PD coverage; as such, “MA” refers to “MA-PD” and “FFS refers to “FFS + PD” in this paper.) D-SNPs are a type of MA plan intended to better meet the needs of dually eligible individuals and are restricted to such individuals. Through 2019, most dually eligible individuals selected FFS coverage, although this proportion has declined (from 80% in 2008 to 59% in 2019). Medicare Advantage enrollment for dually eligible individuals increased from 17% in 2008 to 41% in 20191; much of this can be attributed to D-SNP enrollment, which increased from 10% of all dually eligible individuals in 2008 to 22% in 2019 (12.3 million individuals in 2019).

Compared with other people with Medicare, dually eligible individuals have higher health care needs and costs as well as lower levels of income and assets.3 Dually eligible individuals also face the challenge of navigating 2 complex public health insurance programs with different enrollment criteria, covered benefits, payment structures, and, in some cases, different provider networks.

To help mitigate these challenges, Section 2602 of the Patient Protection and Affordable Care Act (ACA; Pub L No. 111-148) created the Medicare-Medicaid Coordination Office to “make sure dually eligible individuals have full access to seamless, high-quality health care and to make the system as cost-effective as possible.”4 Medicaid covers services or cost-sharing not covered by Medicare, such as long-term care, premiums, and other out-of-pocket costs at the point of care.

D-SNPs were first authorized in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub L No. 108-173), and in 2018 were permanently re-authorized under the Bipartisan Budget Act of 2018 (Pub L No. 115-123). Insurance options for dually eligible people are continuing to evolve. Medicare-Medicaid Plans are an alternative to D-SNPs offered through demonstration projects but are being discontinued by 2025 (they enrolled 3% of people with dual coverage as of 2020).5,6 There also are 3 types of D-SNPs with evolving criteria: Coordination Only, Highly-Integrated D-SNPs (HIDE-SNPs), and Fully Integrated D-SNPS (FIDE-SNPs). In 2020, 24% of all people with dual coverage were enrolled in coordination only D-SNPs, 3% were in HIDE- or FIDE-SNPs, and 51% had FFS coverage.

As an example of the ongoing evolution, Section 3205(b) of the ACA authorized an additional frailty payment by CMS for certain individuals enrolled in FIDE-SNPs. To implement this provision, CMS adopted a regulatory definition of FIDE-SNP, which applied beginning in 2012. FIDE-SNPs directly cover Medicaid benefits for enrollees. Hence, for FIDE-SNPs, the same insurer is at risk for both Medicare and Medicaid spending, which is intended to incentivize the most cost-effective mix of services. In addition, starting in 2013, all D-SNPs subtypes had to contract with a state Medicaid agency. These changes are intended to better integrate Medicaid and Medicare coverage for enrollees in D-SNPs. Research has shown that D-SNPs offer more supplemental benefits than non-SNP MA plans and are more profitable for plan sponsors.

Five studies have considered D-SNP performance for people with dual-eligible coverage relative to other coverage options. Haviland et al compared 2014–2019 experiences of care for people with dual-eligible coverage across the 3 different coverage types and compared performance in this period with performance in earlier years. Using data from 671 913 respondents to the Medicare Consumer Assessment of Healthcare Providers & Systems (MCAHPS) Survey (https://www.ma-pdpcahps.org/), they found that 2015–2019 immunization and overall ratings of care were higher for those in D-SNPs than in the other 2 coverage options. However, D-SNP enrollees did not report better experiences with coordination of care, doctors, or receiving care quickly than similar people in the other 2 coverage options. This study found that experiences with care reported by D-SNP enrollees improved from earlier to later in the study period, making care in D-SNPs more similar to care provided by other coverage types, except regarding immunizations.

Roberts and Mellor used 2015–2019 Medicare Current Beneficiary Survey data to compare experiences of people with dual-eligible coverage across the 3 coverage types on measures of access to care, use of care, and satisfaction with care. They restricted their analysis to those eligible for full Medicaid benefits (including Medicaid services not covered by Medicare as well as coverage of some Medicare cost sharing; see Appendix A). The study used 9885 respondent-year observations and was limited by modest sample sizes. The D-SNP enrollees reported better access to dental care and greater satisfaction with out-of-pocket care expenses and access to specialists than people with dual-eligible coverage in non–D-SNP MA plans. Compared with people with dual-eligible coverage in FFS, D-SNP enrollees also reported better access to a primary care provider, higher rates of 2 of 3 preventive care measures (including an immunization), and greater ease of getting to a doctor from home. Full-benefit D-SNP enrollees did not report better performance on the measures the authors considered related to coordination of care.

A third study compared the use of services for people with dual-eligible coverage in 2 of the 3 coverage types: D-SNPs and non–D-SNP MA (but not the most common option, FFS). Compared with people with dual-eligible coverage in non–D-SNP MA plans, D-SNP enrollees had lower hospital and nursing facility admission rates and higher rates of home- and community-based services.

The fourth study is 1 of only 2 studies to consider Healthcare Effectiveness Data and Information Set (HEDIS) measures of clinical quality and was conducted by the Medicare Payment Advisory Commission. This study compared 2016 clinical quality for people with dual-eligible coverage and enrolled in D-SNPs or non–D-SNP MA (not FFS) but only among a subset of those with dual coverage, those with partial Medicaid benefits (see Appendix A). Those with partial Medicaid benefits comprise approximately 26% of D-SNP enrollees. Medicaid covers any MA premium for those with partial Medicaid coverage but only pays cost-sharing for other services covered by Medicare in some partial Medicaid coverage levels (see Appendix A). For this subgroup, D-SNP enrollees received recommended clinical care at a rate similar to that of non–D-SNP MA plan enrollees on 35 of 39 HEDIS measures for those younger than 65 and 36 of 42 HEDIS measures for those aged 65 or older. For those younger than 65, rates of receiving recommended care were higher in D-SNPs for 2 of the other 4 measures and lower in D-SNPs for the other 2. For those aged 65 or older, rates of receiving recommended care were higher in D-SNPs for 4 of the other 6 measures and lower in D-SNPs for the other 2.

The fifth study, also conducted by the Medicare Payment Advisory Commission,12 compared clinical performance on 33 HEDIS measures between 5 different types of MA plans that are available to people with dual-eligible coverage who select MA coverage. They compared 3 groupings of D-SNPs (Coordination Only, Unaligned HIDE-SNPs and FIDE-SNPs,13 and Aligned HIDE-SNPs and FIDE-SNPs) with Medicare-Medicaid plans and other MA plans with dually eligible enrollees. Across the 5 types of plans and 33 measures, results did not indicate that any of the plan types had consistently better or worse performance than the others. No comparison was made to clinical performance for dually eligible people with FFS coverage.

Overall, D-SNPs have shown similar performance to non–D-SNP MA and FFS on patient experience (including coordination of care), except for higher flu immunization levels. D-SNPs have shown similar performance on clinical measures (HEDIS) for different subgroups of people with dual coverage relative to different types of MA coverage, but no comparisons to FFS (the most common coverage type for people with dual coverage) have been made to date.