Pandemic provisions reduced Medicaid loss for beneficiaries enrolled in both Medicaid and Medicare, study finds

Loss of Medicaid coverage among Americans eligible for both Medicare and Medicaid, known as dually eligible beneficiaries, dropped substantially during the public health emergency, according to a study published in JAMA Network Open this month. COVID due to temporary policy changes.

More importantly, these policy changes, which prohibited states from disenrolling people from Medicaid, reduced and to some extent eliminated the pre-pandemic racial disparity in losing Medicaid coverage.

Our study illuminates the challenges that Medicaid enrollees generally faced in maintaining continuous Medicaid coverage prior to [public health emergency]and the challenges that will likely re-emerge with the resumption of Medicaid redeterminations in 2023, Dr. Yanlei Ma, lead author of the study and research associate in the Department of Health Policy and Management at the Harvard TH Chan School of Public Health, he wrote in an email to The Journalists Resource.

The study, Loss of Medicaid Eligibility Among Dual-Eligible Beneficiaries Before and During the COVID-19 Public Health Emergency, analyzed national Medicare data from 2015 to 2020, tracking 56.2 million records of beneficiaries who were eligible for both Medicare and Medicaid.

The authors focused on dual-eligible beneficiaries “because they represent a particularly vulnerable segment of the healthcare population, often facing complex health needs and socioeconomic challenges, which can complicate their access to needed healthcare services,” they wrote. Ma. In particular, dual eligibles account for about one-third of spending in the Medicare and Medicaid programs, even though they represent only 20% of Medicare and 15% of Medicaid beneficiaries.

About 12.5 million people in the US are enrolled in both Medicare and Medicaid because of their age or disability and low income. This dually eligible population mostly includes people with chronic conditions, physical disabilities, mental illness, and cognitive impairments such as dementia and developmental disabilities.

Medicare is the federal health insurance program for people age 65 and older, certain younger people with disabilities, and people with kidney failure who require dialysis or a transplant. More than 65.7 million people are enrolled in Medicare.

Medicaid is a joint federal and state program that covers health care costs for certain low-income individuals and families, qualifying children and pregnant women, and people age 65 and older who are blind or disabled and have limited income. It is also the main payer for long-term services. Medicaid is the largest source of health coverage in the US with nearly 78 million enrollees.

For dual-eligible beneficiaries, Medicare pays first for Medicare-covered services that are also covered by Medicaid. Medicaid covers services that Medicare doesn’t, according to Medicaid.gov, which has a chart detailing what each program covers.

In 2020, 87% of dually eligible beneficiaries had incomes below $20,000; 40% were under 65; 49% were people of color; and 44% were in fair or poor health, according to a 2023 report by KFF, formerly the Kaiser Family Foundation.

Although dual-eligible beneficiaries remain continuously enrolled in Medicare, many face the risk of losing Medicaid coverage each year due to a variety of factors. These can include income fluctuations, changes in states’ Medicaid eligibility and, in particular, administrative barriers, including burdensome paperwork related to the Medicaid redetermination process, according to the study.

Before the pandemic, the share of beneficiaries who lost Medicaid for at least a month rose from 6.6 percent in 2015 to 7.3 percent in 2019, the study found. Additionally, the authors find that black and Hispanic beneficiaries were more likely to lose Medicaid than their white peers, highlighting that administrative barriers can disproportionately affect people of color.

Ma listed several reasons that contributed to the increase in the Medicaid loss rate between 2015 and 2019, including changes in state eligibility criteria and budget pressures, which may have led some states to seek ways to reduce Medicaid enrollment as a cost-saving measure.

But these trends reversed in 2020.

The share of dually eligible beneficiaries who lost Medicaid for at least a month fell to 2.3 percent, representing hundreds of thousands of people who kept their coverage, the study found.

The study also finds that more than half of dual eligibles who lost Medicaid coverage during the study period regained their Medicaid coverage within a year.

This suggests that coverage losses are less likely to be due to sustained changes in eligibility than to administrative factors, Ma wrote in an email. Eligible individuals may lose Medicaid if they do not receive, understand, or respond in a timely manner to notices or forms that request additional information.

Ma and his co-authors warn that the end of the public health emergency in May 2023, and with it a return to regular Medicaid eligibility redeterminations, could lead to a resurgence of coverage losses. Ma noted that this concern applies to all Medicaid beneficiaries.

Beginning in April 2023, states resumed the Medicaid eligibility redetermination process, also known as Medicaid opt-out, which requires beneficiaries to complete paperwork and provide proof of continued eligibility.

As of April 18, at least 20.3 million Medicaid and CHIP (Children’s Health Insurance Program) beneficiaries nationwide have opted out of the program, according to KFF, which has tracked the opting out of Medicaid. That’s 22% of the 94 million enrolled in Medicaid and CHIP in March 2023, one month before the Medicaid phaseout began.

As states have resumed Medicaid redeterminations, there is a pressing need for policymakers to implement strategies to minimize Medicaid coverage losses, particularly for the most vulnerable and underserved populations, Ma and coauthors write in the study

They recommend that Medicaid eligibility of dual-eligible beneficiaries be determined based on data from other programs, such as the Supplemental Nutrition Assistance Program. They also recommend allowing enrollees more time to respond to requests for additional information, allocating more resources and staff to process eligibility determinations, and providing enrollment materials that are accessible to people with limited English proficiency or disabilities, such as visual impairment.

The authors plan to continue this research to document downward trends as states resume Medicaid redeterminations after the end of the public health emergency, Ma wrote.

Additional resources

• Ma delves into the special needs of dual-eligible beneficiaries in this 2023 Health Affairs podcast, such as homelessness, lack of transportation, or food insecurity.
• A 2019 study published in Health Affairs finds that between 2012 and 2016, 18.2 percent of Medicare beneficiaries receiving full or partial Medicaid dropped out of the program, even though they often continued to receive full subsidies from the Part D income and asset eligibility criteria are closely aligned with Medicaid.
• A 2019 policy report from the US Department of Health and Human Services finds that states with more inclusive Medicaid eligibility coverage policies tend to have less loss of coverage among the new, fully dual ones. [eligibles] than states with more restrictive Medicaid coverage.
• The policy journal Health Affairs is a good source of research studies on Medicaid, Medicare, and dually eligible beneficiaries.
• The independent, nonprofit health policy research organization KFF is a good source of data on Medicare and Medicaid and dual-eligible enrollees, including this January 2023 report on the profile of dual-eligible enrollees.
• Here is a detailed fact book on dual eligible beneficiaries, published in January 2024 by the Medicare Payment Advisory Commission (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC).