Poor, aged people who could qualify for each Medicaid (for being poor) and Medicare (for being aged, blind, disabled or have ESRD). In these instances, Medicaid serves as a supplemental insurer, overlaying Medicare coinsurance and deductibles. The generosity of this supplemental protection for so-called ‘dual-eligibles’ varies throughout states.
These variations in Medicaid funds come up from two sources of coverage variation. First, states differ of their adoption of so-called “lesser-of” insurance policies, that are provisions for Medicaid to pay the decrease of (a) Medicare’s price sharing, or (b) the distinction between the Medicaid price schedule and Medicare’s fee for a service (internet of price sharing).1 Second, Medicaid price schedules, which differ throughout states and over time, have an effect on the quantity of price sharing that Medicaid can pay suppliers in lesser-of states.
In lesser-of states with low Medicaid price schedules, suppliers might be paid considerably much less when rendering companies to duals vs different Medicare beneficiaries, who both pay Medicare’s price sharing out of pocket or have personal supplemental (ie, Medigap) insurance coverage to
cowl these bills.
Unsurprisingly, suppliers usually are not as excited to offer take care of dual-eligibles after they receives a commission much less cash for offering the identical companies they supply to Medicare beneficiaries (see Mitchell et al 2004, Haber et al. 2014, Zheng et al. 2017).
To measure variation in state Medicaid insurance policies concerning twin eligibles, a paper by Roberts et al. (2020) describes the method of making a database of those insurance policies. The sources of the database have been (i) state Medicaid plans and amendments filed with CMS; (ii) state legal guidelines from LexisNexis; (iii) and Medicaid supplier manuals, program bulletins, and associated on-line coverage paperwork. Then the authors created a fee index utilizing a nationally consultant pattern of claims information for analysis and administration companies HCPCS codes. The database is publicly out there right here.
Based mostly on these information, the share of states with <80% protection of Medicare coinsurance and deductibles has grown over time, from 24 states in 2004 to 29 states in 2018. Additional, the variety of states that present full reimbursement fell from 11 in 2004 to 7 in 2018.
One limitation of the info used for this analysis is that it ignores managed care. Medicaid managed care organizations (MCOs) and MCOs are have grown–relative to Medicaid fee-for-service–over time.
Lesser-of insurance policies operate equally below Medicaid managed care, besides that Medicaid MCOs pay the lesser-of (a) the distinction between their negotiated supplier charges and Medicare’s fee quantity, and (b) Medicare’s price sharing. Nonetheless, to the extent fee charges negotiated by Medicaid MCOs differ from these in fee-for-service Medicaid, our fee index won’t precisely replicate supplier funds for duals enrolled in Medicaid MCOs.
Additional, the evaluation additionally doesn’t embody Medicare Benefit beneficiaries. In 2018, Medicare Benefit plans coated 33% of dual-eligibles with full Medicaid.
Nonetheless, the creation of this dataset to trace adjustments in Medicaid dual-eligible generosity is actually a helpful contribution to the literature.