Resource Library

In Improving Care Coordination, the case study contrasts the consequences of weak versus effective care coordination across Medicare and Medicaid. Ms. T’s experience shows how limited integration and inadequate plan support can lead to improper billing, unresolved provider issues, and ultimately a disruption in care when her therapist drops her. In contrast, Mr. Y’s story demonstrates how strong care coordination within a fully integrated plan can proactively protect access to critical services, including uninterrupted 24-hour home care. Together, these examples highlight the essential role of care coordination in reducing administrative burden, preventing care disruptions, and improving outcomes for dually eligible individuals.

In Stopping Coverage Loss and Disruption, the case study focuses on “churn,” or the loss and regaining of coverage, and how it can interrupt care and destabilize integrated plans. Mrs. E’s experience shows how administrative errors in Medicaid recertification can lead to the loss of both Medicaid and integrated D-SNP coverage, resulting in higher costs, missed care, and fragmented services. Mr. V’s story highlights how misleading marketing and confusion about plan options can push beneficiaries out of highly integrated coverage into less coordinated plans, putting critical services like home care at risk. Together, these cases underscore the need for stronger safeguards, clearer communication, and streamlined processes to prevent unnecessary coverage disruptions and protect access to care.

In Closing Gaps in Benefits and Services, the case study examines how differences in Medicare and Medicaid coverage rules, vendors, and plan structures can create barriers to essential services like transportation. Mrs. W’s experience shows how limited integration and misleading expectations around supplemental benefits can leave beneficiaries with less access to care than before, while Mr. L’s story demonstrates how more aligned or integrated plans can simplify access and reduce administrative burdens. Together, these examples highlight the need for clearer plan information, stronger oversight of supplemental benefits, and greater alignment between Medicare and Medicaid to ensure beneficiaries receive the services they need.

In Fixing the Appeals Process, the case study contrasts two beneficiary experiences to show how fragmented versus integrated systems impact access to care. Mr. H’s story illustrates the confusion and delays that arise when Medicare and Medicaid appeals operate separately, leaving him caught between two plans and unsure how to secure coverage for a medically necessary wheelchair feature. In contrast, Mrs. Z benefits from an integrated appeals system that streamlines decision-making and reduces administrative burden, ultimately improving her access to needed services. Together, these examples underscore the importance of aligning Medicare and Medicaid processes and inform policy recommendations aimed at simplifying appeals and strengthening care coordination.