a worker holding an older adult's hand

The most vulnerable people could be adversely affected by the Medicare Payment Advisory Committee’s (MedPac) recent recommendation to change the benchmark policy for growing Medicare Advantage (MA) plans. Allison Rizer, who tracks Medicare and Medicaid for ATI Advisory, made that assessment to McKnight’s Home Care Daily.

Rizer fears partial dual eligible beneficiaries — Medicare enrollees who also receive modest Medicaid benefit — could lose valuable services if MA plans are forced to reduce offerings to compensate for a possible change in the maximum amount the Centers for Medicare and Medicaid Services (CMS) will pay them. 

Allison Rizer

“They have a high level of need. They need personal care services, but they don’t qualify for them (under Medicaid), so that’s where the Medicare Advantage plans can come in,” Rizer said. “These Medicare Advantage plans are able to piece together these benefits in a way that may help prevent them from further decline.” 

ATI Advisory recently published a report on the complex needs of partial dual eligibles and policy changes that could benefit this cohort. Dual eligibles are Medicare beneficiaries who also receive some level of Medicaid support. Those benefits can include everything from prescription drugs to transportation to long-term care. Partial dual eligibles are Medicare beneficiaries who get some financial assistance from Medicaid to cover the cost of Medicare premiums and cost-sharing but don’t receive Medicaid services and long-term care support. 

Partial dual eligibles currently comprise about a third of the 12 million people who receive both Medicare and Medicaid benefits, but they are growing at a faster rate than dual eligibles. Rizer said this group also tends to be sicker and struggle with more social determinants of health. Many older adults at home qualify as partial dual eligibles. 

“They are low-income but typically they have enough assets where they don’t qualify for full Medicaid in their state, so they are still very economically vulnerable,” Rizer said. “They have really high rates of social needs and in some cases housing instability.” 

ATI has laid out a list of policy initiatives that could address the needs of partial dual eligibles. The list includes continued enrollment in MA dual eligibles special needs plans (DSNPs), a special “deeming” period that would allow enrollees to remain in special needs plans if their status changed temporarily due to a change in income, and a CMS test program to address the long-term service and supports of partial dual eligibles. 

Dual and partial dual eligibility varies from state to state. Connecticut and the District of Columbia, for instance, allow beneficiaries to have higher income levels to qualify for dual eligibility. The Biden administration’s plan to provide $400 billion in home-and-community-based services could potentially translate into more state Medicaid funding. That could allow states to lower income requirements for dual eligibility, so people who are partially dual eligible now could receive services.

Even though many partial dual eligible beneficiaries eventually spend down their income to the point where they become eligible for full Medicaid benefits, Rizer said the delay can ultimately be costly to the health of those beneficiaires and the healthcare system.

‘If we can target some of their social needs now, if we can target some of their functional needs now, we are able to move upstream from some of those more consequential impacts on the healthcare system,” said Rizer.

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