Dual Eligibles Fast Facts


dual eligibles by age groupAbout 1.1 million low-income seniors and people with disabilities in California receive health care services through both the Medicare and Medi-Cal (Medicaid nationally) programs. These people commonly are called dual eligible beneficiaries or “dual eligibles.”

No more than 456,000 dual eligible beneficiaries will be eligible to participate in California’s demonstration projects to coordinate Medicare and Medi-Cal — called the Cal MediConnect program.

In California, as many as seven in ten dual eligibles are age 65 and older, and the majority are women.[1] Approximately one in three are younger people with disabilities. Additionally, they tend to have low incomes; more than half live on $10,000 a year or less.[2] While a diverse group overall, dual eligibles often have multiple chronic health conditions and rely on an array of health and long-term services and supports.

CMS prepared a summary profile with charts describing California’s dual eligible population demographics, utilization and spending.

More info: Click on the questions below to learn more about California’s dual eligible population.

  1. How does someone become a dually eligible beneficiary?
  2. Where do dual eligible beneficiaries live in California?
  3. What needs do dual eligible beneficiaries have?
  4. How do dual eligible beneficiaries access services today?
  5. Do all dual eligible beneficiaries receive the same benefits?

 

How does someone become a dually eligible beneficiary?

People typically become dual eligibles by first being enrolled in one program and later becoming eligible for the other program.  For example, an elderly person with Medicare may “spend down” his or her income by paying for long-term care services and then meet the income cut-off to qualify for Medi-Cal’s wrap-around benefits. Or, someone may already meet Medi-Cal’s low-income requirements and age into Medicare when he or she turns age 65. People also may receive Medi-Cal as a result of a disabling condition and after a two-year waiting period qualify for Medicare.

 

Where do California’s dual eligible beneficiaries live?

Every county in California has some individuals who receive both Medicare and Medi-Cal benefits. Ten counties are home to about 75 percent of dually eligible beneficiaries, with Los Angeles County home to nearly one in three. The five counties with the most beneficiaries are Los Angeles (370,000), San Diego (76,000), Orange (71,500), San Bernardino (53,000), and Santa Clara (50,000).[3]

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What needs do dual eligible beneficiaries have?

The dual eligible population is three times more likely live with a disabling condition than the general Medicare population. Dual eligibles also are more likely to have greater limitations in activities of daily living (ADLs), such as bathing and dressing. Dual eligibles are also more likely than nonduals to suffer from cognitive impairment and mental disorders. They have higher rates of pulmonary disease, diabetes, stroke, and Alzheimer’s disease.[4] As a result of these high health needs, many need in-home care providers plus a range of doctors and other health and social services.

Learn more: National Senior Citizens Law Center Fact Sheet on Dual Eligible Beneficiaries

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How do dual eligible beneficiaries access services?

Currently, about 80% of dual eligibles in California receive care on a “fee-for-service” basis, meaning the state or federal government pays a fee each time they visit a doctor, have a test done or enter the hospital. Dual eligibles must carry multiple insurance cards and know different program rules because they have to navigate two and often three or more separate systems to receive care. Research shows this can make it difficult to get the appropriate services at the right time and place and can lead to duplication of tests and procedures and sometimes unnecessary hospitalizations.[5]

The need to expand care coordination to dual eligibles is so great that, under the federal Affordable Care Act, the government created a new office – the Medicare-Medicaid Coordination Office (MMCO). This office is working with several states, including California, to design demonstration projects that aim to significantly improve the health and quality of life for dual eligibles while containing costs through enhanced care coordination.

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Do all dual eligible beneficiaries receive the same benefits?

Dual eligibles do not necessarily receive the same benefits from Medicare and Medi-Cal depending on various eligibility rules, such as their income or number of working years they contributed taxes to the Medicare trust fund.

Broadly, dual eligibles fall into these groups:

  • Nearly all are “full benefit” beneficiaries, meaning they have Medicare Parts A, B, and D coverage, and Medi-Cal coverage for Medicare premiums, co-insurance, copayments, and deductibles, as well as additional services covered by Medi-Cal but not Medicare.
  • A small number (about 2%) are “partial benefit” dual eligibles. These beneficiaries do not qualify for full-scope Medicare and/or Medi-Cal benefits.
  • Share of cost” dual eligibles are another subset. This group receives full benefits but to meet the Medicaid income cut-offs must “spend down” excess income on medical expenses each month. Most beneficiaries with a share of cost reside in long-term care facilities and are assumed to have met their share of cost each month.

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Citations
[1] California Department of Health Care Services. Medi-Cal’s Dual Eligible Population Demographics, Health Characteristics, and Costs of Health Care Services.Research and Analytics Studies Section; 2009.

[2] Henry J. Kaiser Family Foundation. Dual Eligibles: Medicaid’s Role for Low-Income Medicare Beneficiaries. Kaiser Commission on Medicaid Facts; May 2011. http://www.kff.org/medicaid/upload/4091-08.pdf

[3] Research and Analytic Studies Section, California Department of Health Care Services. Available at http://www.dhcs.ca.gov/dataandstats/statistics/Documents/20_AVG_Monthly_Dual_Eligible_LTC_Users_by_County_2010.xls

[4] Medicare Payment Advisory Commission (MedPAC). Report to Congress: New Approaches in Medicare, Chapter 3: Dual Eligible Beneficiaries, an Overview, June 2011.

[5] Chattopadhyay A, Bindman AB. Linking a Comprehensive Payment Model to Comprehensive Care of Frail Elderly Patients. JAMA: The Journal of the American Medical Association. 2010;304(17):1948 -1949.

[6] California Department of Health Care Services. Medi-Cal’s Dual Eligible Population Demographics, Health Characteristics and Costs of Health Care Services. Research and Analytics Studies Section; 2009.

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