Risk Adjustment

Medicare Dual Eligibles: A Significant Opportunity for Health Plans and Members Alike

According to recent data, there are 59.7M Medicare beneficiaries.1 Approximately 32% of those beneficiaries are under 200% of the federal poverty level2 and are potentially eligible for Medicaid. Although the number of enrolled dual eligible members (duals) has increased from 8.6M in 2006 to 12M in 2017,3 there is still a significant amount who are currently unidentified, representing a tremendous opportunity for health plans who need to implement or optimize their campaigns.


Dual Eligibility: Healthier, Less Risky Populations


For health plans, identifying the population of duals is productive because this group is made up of chronically ill individuals who have multiple co-morbidities. According to a report by CMS,4 60% of duals have multiple chronic conditions, 41% have been diagnosed with at least one type of mental illness, and 49% receive long-term care services and supports. As a result, this population incurs the most disproportionate level of costs. In fact, duals make up 34% of all Medicare spending—$498.9B.5

When Medicare plans accurately and consistently identify duals, they receive higher premiums—between 20 and 40 percent higher. Since duals also have higher RAF scores, insurers are reimbursed accordingly. Identifying duals also benefits ACOs because their members get more expansive benefits and it raises their bids.


Being Left Out


Medicare beneficiaries who remain unidentified as dual eligible will continue to struggle with poor health and hardship. They’re forced to pay full premiums, deductibles, co-pays, and maximum out of pocket costs. Perhaps the most evocative statement that can be made about their situation is that they often have to choose food over health care costs.

According to a 2014 report by Feeding America,6 66% of households—17% of which are 60 and older—say they had to choose between paying for food or paying for medicine or medical care in the past year. What’s more, 30% said they faced this tough decision every month.

While some Medicare beneficiaries are unaware they are Medicaid eligible, others simply failed to re-enroll. In at least one state this segment has been found to be 32%. However, once properly identified and enrolled, duals in most states have partially or fully-subsidized premiums. They also have access to SNAP, home health services, transportation, and home and community-based services, among others. The supplementary services improve health outcomes more holistically, addressing factors related to social determinants of health and quality of life.


How to Identify, Engage and Enroll Dual Eligibles


Identifying duals starts with the data. The more comprehensive the better, but the member information that’s nearly universal is more useful than it may seem at first glance. For example, poverty has been shown to be tied closely to geography. Therefore, a zip code is a powerful indicator of income as well as health outcomes. Still, confident targeting requires more detail than location.

Segmentation will depend on the quality of member data and the capacity to perform analytics. What’s more, no amount of geographic, demographic, or historical data will actually engage members. Outreach and enrollment should be built around outreach agents that have a detailed understanding of how to engage patients. The duals enrollment process often involves handling not only healthcare data, but additional sensitive information like bank records, employment history, and income level. Knowing how to gain the trust of dual-eligible members during the enrollment process is critical to making them feel at ease transferring sensitive records.

Many plans will find dual-eligible identification and effective member outreach are disparate specialties that are often either difficult to coordinate internally or unavailable. Whether it’s for administrative or financial reasons, health plans looking to implement or optimize their duals strategy will inevitably want to consider third party support. A partnership should come with greater capacity to identify members by eligibility, as well as offer a suite of services to reach and enroll those members.

Episource has the expertise to identify, engage and enroll members, and ensure re-enrollment each year. To learn more, contact us today.


  1. CMS Fast Facts
  2. Distribution of Medicare Beneficiaries by Federal Poverty Level
  3. Data Analysis Brief: Medicare-Medicaid Dual Enrollment 2006 through 2018
  4. People Dually Eligible for Medicare and Medicaid
  5. A Primer on Medicare: Key Facts About the Medicare Program and the People it Covers
  6. Hunger in America 2014



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