Join Us Live for a Discussion on Medicare, Democracy, and the Future of Health Care
Distinct Medicare and Medicaid rules, funding streams, and service delivery systems can create barriers that increase costs and worsen outcomes for people who are jointly enrolled in the programs. We support correcting this fragmentation through policies that offer meaningful choice; reduce disparities in access to and quality of care; rely on active and informed enrollee participation; include robust safeguards and oversight; offer clear enrollee and provider education about options for accessing integrated care; establish unified grievance and appeals processes; ensure seamless access to data; and provide person-centered care coordination and care management.
Policymakers often overlook or disregard the problems people may face when they try to enroll or stay enrolled in public programs or to get the care they need. Issues around Medicare and Medicaid enrollments and appeals are legion and can run the gamut from minor one-time annoyances to recurrent bureaucratic nightmares.
Medicaid is financed and administered through a federal-state partnership. Under current law, the federal government matches state Medicaid spending based on a statutory formula, without a pre-set limit. If state spending increases, for example due to increased enrollment or unexpectedly high program costs, then federal spending increases as well.
With the passage of HR 1, Congress is cutting around $1 trillion from Medicaid over the course of the next 10 years. The cuts will affect Medicaid at every level, restricting eligibility and enrollment, driving up the cost of covered services for beneficiaries and states, and damaging the health care system nationwide. These cuts harm the people who rely on the program, including millions of older adults and people with disabilities who are dually eligible for Medicare and Medicaid, as well as people nearing Medicare eligibility who have coverage through expansion Medicaid.
Many states have expanded Medicaid coverage and care through Medicaid “Section 1115” waivers, but some states are inclined to move in the opposite direction, to limit eligibility or restrict coverage.
For people enrolled in both Medicare and Medicaid, dual eligibility should mean better access, more benefits, and streamlined processes. But
Nearly 1 in 5 people with Medicare are also enrolled in Medicaid. For these dually eligible beneficiaries, Medicare acts as
New York, NY—Millions of people rely on both Medicare and Medicaid to access affordable health care, but when the two
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.
Policymakers often overlook or disregard the problems people may face when they try to enroll or stay enrolled in public programs or to get the care they need. Issues around Medicare and Medicaid enrollments and appeals are legion and can run the gamut from minor one-time annoyances to recurrent bureaucratic nightmares.
Medicaid is financed and administered through a federal-state partnership. Under current law, the federal government matches state Medicaid spending based on a statutory formula, without a pre-set limit. If state spending increases, for example due to increased enrollment or unexpectedly high program costs, then federal spending increases as well.
With the passage of HR 1, Congress is cutting around $1 trillion from Medicaid over the course of the next 10 years. The cuts will affect Medicaid at every level, restricting eligibility and enrollment, driving up the cost of covered services for beneficiaries and states, and damaging the health care system nationwide. These cuts harm the people who rely on the program, including millions of older adults and people with disabilities who are dually eligible for Medicare and Medicaid, as well as people nearing Medicare eligibility who have coverage through expansion Medicaid.
Many states have expanded Medicaid coverage and care through Medicaid “Section 1115” waivers, but some states are inclined to move in the opposite direction, to limit eligibility or restrict coverage.
For people enrolled in both Medicare and Medicaid, dual eligibility should mean better access, more benefits, and streamlined processes. But
Nearly 1 in 5 people with Medicare are also enrolled in Medicaid. For these dually eligible beneficiaries, Medicare acts as
New York, NY—Millions of people rely on both Medicare and Medicaid to access affordable health care, but when the two
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.
