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The article from JAMA Network Open explores the financial implications of dual-eligible beneficiaries—those who are eligible for both Medicare and Medicaid—on healthcare spending. It highlights that dual-eligible individuals account for a significant portion of both Medicare and Medicaid program costs due to their complex healthcare needs, including chronic conditions and long-term services and supports (LTSS). The study emphasizes that while dual-eligibles represent approximately 20% of the Medicare population and 15% of the Medicaid population, they account for a disproportionately high share of healthcare spending, with Medicare spending much higher for dual-eligibles compared to non-dual beneficiaries. The article sheds light on how the integration of care across these two programs could help reduce fragmentation and improve care coordination, leading to more efficient use of resources.

The article also delves into the challenges of integrating Medicare and Medicaid services for dual-eligible individuals, which is often hindered by the complexity of having two separate systems. Despite efforts to integrate care through initiatives like Dual-Eligible Special Needs Plans (D-SNPs), the lack of full coordination between Medicare and Medicaid still leads to inefficiencies and higher costs. The study calls for policy changes that encourage more seamless integration between the two programs and better care coordination, which could potentially lead to improved outcomes for dual-eligible individuals while also reducing the financial strain on both Medicare and Medicaid systems.

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2829453 

1. Expanded Access to Dual Eligible Special Needs Plans (D-SNPs):

• • Overview: CMS has been working to expand access to D-SNPs, which are Medicare Advantage plans tailored specifically for dual-eligible individuals.
  • Key Change: New regulations will likely make it easier for states to expand their D-SNP offerings and integrate Medicaid and Medicare benefits more effectively. This will improve care coordination and ensure that dual-eligible beneficiaries have access to more comprehensive healthcare coverage.
  • Impact: Dual-eligible individuals may see broader options for integrated care, with more plans designed to meet their specific needs.

2. Enhanced Consumer Protections and Cost-Sharing Reductions:

• • Overview: The Biden administration has proposed measures that would further reduce cost-sharing and improve financial protections for dual-eligible individuals.
  • Key Change: There are expectations of changes to limit out-of-pocket costs for dual-eligible individuals, especially for D-SNP beneficiaries. This includes reducing cost-shifting to Medicaid and ensuring that dual-eligible enrollees are not subject to high out-of-pocket costs, particularly in areas like prescription drugs and long-term care services.
  • Impact: Dual-eligible individuals may experience lower costs for healthcare services, making care more affordable and reducing financial burdens.

3. Strengthened Integration of Medicare and Medicaid Benefits:

• • Overview: Integration of Medicare and Medicaid services has been a key focus of policy changes to improve care coordination for dual-eligible individuals.
  • Key Change: We anticipate further policy changes to ensure better integration of Medicare and Medicaid benefits, particularly for individuals receiving long-term services and supports (LTSS). The focus will be on improving coordination across providers and reducing fragmentation in care delivery.
  • Impact: Dual-eligible individuals will have a more streamlined experience when accessing healthcare, reducing the need for multiple providers and improving health outcomes through better care management.

4. State-Level Flexibility to Expand Managed Care Programs:

• • Overview: Several states are already expanding managed care programs for dual-eligible populations, with Florida and others leading the way.
  • Key Change: Federal policies are expected to give states more flexibility to create and expand Medicaid managed care programs that integrate Medicare services for dual-eligible individuals.
  • Impact: States may have the ability to offer more tailored, flexible care options to their dual-eligible populations, improving local access to services and support.

5. Long-Term Services and Supports (LTSS) Focus:

• • Overview: The growing need for long-term services and supports for dual-eligible individuals is driving policy changes aimed at improving access to these services.
  • Key Change: The federal government is expected to continue prioritizing LTSS, including home- and community-based services (HCBS). This could include expanded funding for HCBS and a shift from institutional care to community-based models that allow individuals to live more independently.
  • Impact: Dual-eligible individuals will likely see increased access to long-term care options that are more aligned with their personal preferences and needs, including more options to receive care at home or in the community rather than in institutional settings.

6. Focus on Health Equity and Access for Vulnerable Populations:

• • Overview: There is increasing recognition of the need to address health disparities among dual-eligible individuals, particularly those from marginalized communities.
  • Key Change: Anticipated policies will focus on addressing these disparities by improving access to care, increasing cultural competency among providers, and expanding services for underserved populations.
  • Impact: Dual-eligible individuals, especially those from low-income, rural, and minority backgrounds, will likely have greater access to quality healthcare services that are tailored to their specific cultural and community needs.

These anticipated policy changes for 2025 represent significant steps forward in improving the healthcare experience for dual-eligible individuals, with a strong focus on coordination, affordability, and access to services that meet their comprehensive healthcare needs.