State Profiles for Dual-Eligible Individuals
United States Medicare and Medicaid Coverage Arrangements for Dual-Eligible Individuals
Medicare & Medicaid coverage arrangements, number of Medicaid delivery systems, & use of Medicaid wraparound services
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Dual-eligible individuals with full Medicaid benefits usually have Medicare benefits covered under traditional Medicare or Medicare Advantage and, separately, Medicaid benefits covered through Medicaid fee-for-service or Medicaid managed care (also known as Medicaid delivery systems). Existing coverage arrangements for dual-eligible individuals vary in how benefits are coordinated, and how plans and providers are paid. For example, in traditional Medicare, dual-eligible individuals (as with other Medicare beneficiaries) may be aligned to an accountable care organization (ACO), which is a group of providers that work together to coordinate care. In Medicare Advantage, dual-eligible individuals may be enrolled in special needs plans, which can tailor benefits to specific populations and have various requirements to coordinate with Medicaid. Full-benefit dual-eligible individuals may be enrolled in multiple Medicaid delivery systems even though Medicaid only covers services that are not otherwise covered by Medicare, including long-term care, vision, and dental care (also known as wraparound services). A small percentage of dual-eligible individuals have most of their Medicare and Medicaid benefits covered through a single plan or program.
Summary of Coverage Arrangements, United States
| Indicator | Value |
|---|---|
| Summary Text | Nationally, 5% of full-benefit dual-eligible individuals received their Medicare and Medicaid benefits through a single plan, either the Program of All-inclusive Care for the Elderly or a Medicare-Medicaid Plan, in 2021. The remaining 95% received their benefits through separate coverage combinations, with the most common being traditional Medicare and Medicaid fee-for-service (28%). For Medicaid benefits, 4.4 million full-benefit dual-eligible individuals were enrolled in more than one Medicaid delivery system. Nearly 5 million full-benefit dual-eligible individuals used Medicaid wraparound services, including long-term care, in 2021. |
Distribution of Full-Benefit Dual-Eligible Individuals by Medicare and Medicaid Coverage Arrangements, 2021, United States
| Indicator | Value |
|---|---|
| Single Plan (Medicare & Medicaid) | 0.05 |
| Traditional Medicare & Medicaid FFS | 0.28 |
| Traditional Medicare & Medicaid Managed Care | 0.23 |
| Medicare Advantage & Medicaid FFS | 0.19 |
| Medicare Advantage & Medicaid Managed Care | 0.24 |
Single plan includes Medicare-Medicaid Plans (MMPs) and the Program of All-Inclusive Care for the Elderly (PACE). Medicaid FFS is fee-for-service. Medicaid managed care includes managed medical or long-term care coverage but not other types (such as behavioral health plans). Only the coverage arrangements or programs that were available in the state as of March of the reporting year are displayed. Totals may not equal 100% due to data suppression and rounding.
Coverage arrangement categories are mutually exclusive. See The Landscape of Medicare and Medicaid Coverage Arrangements for Dual-Eligible Individuals Across States for details on how the Medicare/Medicaid coverage arrangements are defined.
Source: KFF analytic file of merged 2021 MBSF and 2021 T-MSIS data.
Distribution of Full-Benefit Dual-Eligible Individuals by Medicare Coverage Arrangements, 2021, United States
| Indicator | Value |
|---|---|
| Traditional Medicare with ACO alignment | 0.12 |
| Traditional Medicare with no ACO alignment | 0.39 |
| Individual Medicare Advantage Plans | 0.14 |
| Special Needs Plans (SNPs) | 0.29 |
| Single Plan (Medicare & Medicaid) | 0.05 |
Single plan includes Medicare-Medicaid Plans (MMPs) and the Program of All-Inclusive Care for the Elderly (PACE). Coverage arrangement categories are mutually exclusive and reflect enrollment in March. Totals may not equal 100% due to data suppression and rounding.
See The Landscape of Medicare and Medicaid Coverage Arrangements for Dual-Eligible Individuals Across States and the definitions on the bottom of the page for more details on Medicare and Medicaid coverage arrangements.
Source: KFF analytic file of merged 2021 MBSF and 2021 T-MSIS data.
Distribution of Full-Benefit Dual-Eligible Individuals by Number of Medicaid Service Delivery Systems, 2021, United States
| Indicator | Value |
|---|---|
| One Medicaid Delivery System | 3573100 |
| Two Medicaid Delivery Systems | 3683900 |
| Three or More Medicaid Delivery Systems | 685700 |
| Total | 7942700 |
NSD indicates not sufficient data (cells representing fewer than 50 enrollees). National totals exclude Alabama, Arkansas, and Idaho due to data quality issues in those states.
Delivery system categories are mutually exclusive. See The Landscape of Medicare and Medicaid Coverage Arrangements for Dual-Eligible Individuals Across States for details on how the delivery systems are defined and counted.
Source: KFF analytic file of merged 2021 MBSF and 2021 T-MSIS data.
Number of Full-Benefit Dual-Eligible Individuals Using Medicaid Wraparound Services, 2021, United States
| Indicator | Value |
|---|---|
| Any Wraparound Service | 4702500 |
| Institutional LTC | 792200 |
| Home Care (HCBS) | 2197100 |
| Vision Services | 1934800 |
| Dental Services | 1444800 |
| Non-Emergency Medical Transportation | 1029200 |
LTC represents long-term care. Home care is also known as home- and community-based services or HCBS. Analysis includes dual-eligible individuals with at least 10 months of full Medicaid benefits. Due to data quality issues in 2021, Mississippi data are sourced from 2019 T-MSIS data. Due to data suppression and rounding, subgroup estimates may not sum to the total.
Source: KFF analytic file of merged 2021 MBSF and 2021 T-MSIS data.
Definitions
Traditional Medicare (TM): Beneficiaries can obtain care from any provider that participates in Medicare.
Accountable care organization (ACO) alignment: An Accountable Care Organization is a value-based payment model in which groups of doctors, hospitals, and other health care providers voluntarily form partnerships to collaborate and share accountability for the quality, coordination, and cost of care delivered to their patients. Beneficiaries in traditional Medicare are ‘aligned’ to an ACO based on claims data or patient attestation. This analysis includes beneficiaries aligned to Medicare Shared Savings Program ACOs, but not those aligned to ACO models being tested by the Center for Medicare and Medicaid Innovation.
Medicare Advantage: Private plans that receive a payment per enrollee from the federal government to deliver Medicare Part A and Part B benefits, typically, Part D drug coverage, and usually supplemental benefits. Individual plans are generally available for enrollment to all people with Medicare. In addition, employers and unions may sponsor plans for their retirees. These plans may enroll dual-eligible individuals but do not coordinate Medicare and Medicaid benefits.
Special Needs Plan (SNP): A type of private Medicare Advantage plan that restricts enrollment to Medicare beneficiaries that meet certain conditions. For the purposes of reporting enrollment shares, Dual Eligible Special Needs Plans, Chronic Condition Special Needs Plans, and Institutional Special Needs Plans are combined.
Dual Eligible Special Needs Plan (D-SNP): A type of private Medicare Advantage plan designed for dual-eligible individuals and provide Medicare-covered services and in most cases supplemental benefits. The degree of coordination and coverage of Medicaid benefits depends on the type of dual eligible special needs plan. D-SNPs are required by Medicare to have contracts with Medicaid programs in the states in which they operate and meet minimum requirements. The descriptions below reflect requirements in 2021, consistent with the year of data displayed.
Coordination-only D-SNPs: This type of D-SNP provides Medicare-covered services and is required to coordinate the delivery of benefits with the Medicaid program, contract with state Medicaid programs, and notify states when enrollees are admitted to inpatient facilities.
Highly Integrated D-SNPs (HIDE SNP): must meet the requirements of coordination-only D-SNPs and must also have a Medicaid plan operating in the same counties as the D-SNP.
Fully Integrated D-SNPs (FIDE SNP): must meet the requirements of coordination-only D-SNPs and provide Medicare and included Medicaid covered services through a single managed care organization.
Chronic Condition Special Needs Plans (C-SNP): Chronic condition special needs plans are a type of private Medicare Advantage plan that enrolls individuals who have specific severe or chronic disabling conditions.
Institutional Special Needs Plans (I-SNP): Institutional special needs plans are a type of private Medicare Advantage plan that enrolls individuals who need services to be provided in a long-term care facility for at least 90 days.
Single Plan: Includes Medicare-Medicaid Plans (MMPs), which were established as a demonstration under the Financial Alignment Initiative, and the Program of All-Inclusive Care for the Elderly (PACE). As of January 1, 2026, MMPs must be transitioned to integrated D-SNPs.