Beneficiaries who are enrolled in both Medicare and Medicaid are referred to as “dually eligible.” The number of these members is increasing, and as health plans serve more dual-eligible members, they are challenged to find innovative ways to serve this population and address their unique needs.

The Needs of Dual Eligible

Many dual eligible have needs that are significantly more involved than the average health plan member, including complex medical issues, behavioral health concerns, and the need for additional support services. Consider these statistics: *

  • 41 percent of dually eligible individuals have at least one mental health diagnosis
  • 49 percent receive long-term care
  • 60 percent have multiple chronic conditions
  • 18 percent  report they have “poor” health

What Can Health Plans Do?

The Center for Health Care Strategies, with support from The Commonwealth Fund, created a learning collaborative called Promoting Integrated Care for Dual Eligible. Seven participating health plans collaborated to find ways to better deliver care to meet the unique needs of the dual eligible population. Following is a summary of their recommendations:

Meet the member’s immediate needs first.

While getting members access to health care is top of mind for plans, it may not be the most pressing concern for a dually eligible individual. Plans should focus on developing relationships with members to determine their most immediate needs – and then addressing them. That might mean fixing a broken wheelchair ramp or providing a meal. By addressing these concerns, plans can build trust and remove obstacles in the way of getting these members care.

Let the member set the pace.

Developing trust also comes into play as plans work to connect with members to complete initial health risk assessments. Plans should try offering multiple opportunities for connecting in a variety of settings, including in-home and offsite locations, that may make the member more comfortable.

Empower members to initiate contact.

When possible, allow the member to reach out to the plan instead of vice versa. Plans may need to consider creative strategies and communications that help the member feel empowered to take action to make contact.

Hire staff who can relate to members.

Hiring health care navigators from the community can facilitate connection for health plans. These employees can help plans build connections, identify needs, and overcome barriers, including language and culture.

Offer alternative settings for contact.

Members may not be comfortable meeting in their homes. Or some members may be struggling with homelessness. Offering a safe, convenient offsite location to meet with members can expedite contact.

Create connections to members through local organizations.

Community organizations are champions for their constituents. Consider how plans can develop relationships with organizations that will help build trust between the members of the community and the plan.

Identify unique preferences of cultural subpopulations.

Is your plan serving a population with unique cultural mores? Plans should consider how they can adapt to connect with members in a way that makes the member comfortable.

Help members obtain and/or maintain benefits.

Dually eligible members are often balancing multiple streams of support and maintaining benefits can present a challenge. When plans ensure members do not lose benefits, like food support or Social Security Income benefits, they help provide stability to the member that ultimately contributes to their wellness.

*According to the Centers for Medicaid and Medicare Services March 2020 Fact Sheet.