When all your dual eligible members are enrolled and stay enrolled, Medicare Advantage members and the plan benefit. Members gain access to the coverage and care they are entitled to, helping to improve their overall health and wellness. With higher dual enrollment success, your plan will see a ~21.5% boost in RAF, ensuring more accurate CMS reimbursements.
DUAL ELIGIBLE OVERVIEW
The term “dual eligible beneficiaries” refers to the 12 million low-income seniors and children with disabilities covered by both Medicare and Medicaid. Many of whom live with substantial health needs, including chronic illness, disabilities, and mental health and social issues that can lead to higher care costs.
The CMS payment model for Medicare Advantage (MA) plans doesn’t fully cover these additional care costs if dual eligible members are not enrolled. Recent updates to the CMS reimbursement structure further incentivize MA plans to identify members in their plan populations who are either full or partial dual eligible to ensure reimbursements that accurately account for cost of care for the plan.
HOW IT WORKS
GET STARTED WITH MINIMAL DATA
Smarter data means less work for you. With Episource, you need only MMR-MOR files and basic member information, and we do the rest. No claims data required.
PRECISELY IDENTIFY DUAL BENEFICIARIES
We combine clinical and non-clinical data, including Social Determinants of Health (SDoH) to analyze target populations from a 360-degree angle, ensuring precise identification of dual eligible members.
INDIVIDUALIZED EXPERT OUTREACH
Every potential dual eligible member is assigned a highly skilled enrollment expert who will act as their direct point of contact throughout the entire eligibility and enrollment process. Well trained in guiding members through even the most complex state-specific guidelines, our enrollment experts confirm eligibility and walk them through the entire application process. This hands-on approach better guarantees that those who are eligible for dual enrollment get the coverage they are entitled to.
PAYERS RECEIVE MORE ACCURATE REIMBURSEMENTS
Identifying and enrolling dual eligible members leads to an increase in RAF by 15-25% depending on HCC conditions.
Lift in RAF score for dual eligible members enables more accurate reimbursements for your health plan from CMS.
Medicaid enrollment translates to increase access to care and resources for members, helping them stay healthier over time.
DUAL ELIGIBLE MEMBERS BENEFIT FROM BETTER COVERAGE
Members get increased access to resources and different types of care.
Members receive financial benefits, including Medicare premium or deductible copayment.
Members gain access to additional coverage through Medicaid such as nursing home care, personal care, or home- and community-based services.