Study finds threat to care coordination for people eligible for both Medicare and Medicaid

July 24, 2023 – More than 12 million people in the U.S. are eligible for both Medicare and Medicaid. But it can be challenging for these so-called “dual eligibles”—many of whom have complex health care needs—to navigate their Medicare and Medicaid benefits, which are administered separately.

A type of Medicare Advantage managed care plan called a Dual-Eligible Special Needs Plan, or D-SNP, can help people with dual eligibility integrate their care. But a new study from Harvard T.H. Chan School of Public Health has found a potential threat to integration in the form of D-SNP “look-alike” plans that may lead to poorer quality of care for those who sign up for them.

The study, published July 5 in Health Affairs, was led by Yanlei Ma, postdoctoral research fellow in the Department of Health Policy and Management. Other co-authors from the department included Austin Frakt, Jessica Phelan, and Jose Figueroa.

The researchers found that look-alike plans experienced rapid enrollment growth—an elevenfold increase—among dual eligibles from 2013 to 2020. But, as Ma pointed out in a July 18 Health Affairs podcast, the look-alike plans don’t have to adhere to certain federal and state rules and protocols set for D-SNPs. She said that people with dual eligibility are confusing the look-alike plans with D-SNPs “because certain brokers of look-alike plans misrepresented the characteristics of these plans and made them sound like D-SNPs. As a result, the duals thought they enrolled in a plan that coordinates their Medicare and Medicaid benefits when in fact the look-alike plans have no such obligation.”

The researchers also found that, compared with D-SNPs, look-alike plans were more likely to enroll dual-eligible people who were older, Hispanic, and from disadvantaged communities. “This is concerning, as the look-alike plans seem to be targeting duals with low English proficiency and from underserved areas,” she said. “This disparity in enrollment may ultimately translate to a disparity in health care quality and outcomes.”

To ensure that people sign up for the most beneficial integrated plans, Ma suggested that policymakers consider several options, such as further regulating look-alike plans, allowing D-SNPs to automatically enroll individuals when they first become dual eligible, and providing more education to those with dual eligibility about the difference between integrated and non-integrated plans.

Listen to or read the Health Affairs podcast: Yanlei Ma on Dual-Eligible Special Needs Plans