Dual Eligibles


About 9 million people in the United States are covered by both Medicare and Medicaid, including low-income seniors and younger people with disabilities. These Medicare-Medicaid eligible beneficiaries have complex and often costly health care needs, and have been the focus of many recent initiatives and proposals to improve the coordination of their care aimed at both raising the quality of their care while reducing its costs.

The materials, below, provide the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) perspective on recent efforts. Other resources provide information on state proposals, and examine the dual eligible population, their health care needs and spending, and ongoing efforts to coordinate care across the two programs.

Contact Mike Cheek​ with questions. 

Current Medicare-Medicaid Integration Efforts

The Affordable Care Act (ACA) established two new offices in the U.S. Department of Health and Human Services (DHHS) aimed at testing new and innovative ways of delivering high quality services to people who are eligible for both Medicare and Medicaid.  These offices are the Medicare-Medicaid Coordination Office (MMCO) and the Center for Medicare and Medicaid Innovation (CMMI).  MMCO leads on shaping state Financial Alignment proposals to better align Medicare and Medicaid for people who are eligible for both while CMMI provides the financing. 

For more information on the financial alignment approaches, click here.  Below is a snapshot comparing the two methods: capitated, risk-based (or managed care) and managed fee-for-service, which states may use under CMS’ current Medicare-Medicaid Financial Alignment Initiative.

Overview of Financial Alignment Methods 

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Below is a snapshot of state levels of interest.

Financial Alignment Initiative State Overview

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To-date, CMS and two states have entered into Memoranda of Understanding (MOU), the second step in the financial alignment initiative implementation process.  The Commonwealth of Massachusetts received approval first.  To view AHCA’s analysis, click here. Massachusetts is the first example of a managed care approach to Medicare-Medicaid Integration.  In October 2012, CMS entered into a second MOU.  Under this agreement with Washington State, CMS and the state will implement a statewide managed fee-for-service (MFFS) approach to Medicare-Medicaid integration.  For an overview of MFFS as well as an analysis of the Washington State MOU, click here. An overview of state activity is presented in the map, below.

State-by-State Medicare-Medicaid Financial Alignment Initiative Overview



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AHCA Position on Medicare-Medicaid Financial Alignment

AHCA/NCAL supports the overarching goal of offering persons who are Medicare-Medicaid eligible high quality, seamless and cost effective care through integrated, person-centered services.  However, the post-acute and long-term care (PAC-LTC) industry has a number of concerns regarding the state Medicare-Medicaid integration proposals. 
AHCA/NCAL key concerns include:

  • Medicare-Medicaid initiatives must be pilot or demonstration projects and serve to inform national Medicare and Medicaid integration efforts.  The ACA did not authorize the U.S. Department of Health and Human Services (DHHS) to restructure the Medicare and Medicaid programs for this population but rather test discreet models. 
  • State and managed care plan experience is not well positioned to support rapid program proliferation and expansion particularly in long term care;
  • People should have ample opportunity to make educated choices about how they will receive their services and supports; and
  • Provider reimbursement must ensure access and overall provider network operational and financial stability.

The National Senior Citizens Law Center has developed a robust website, called Duals Demo Advocacy on the financial alignment initiative offering talking points from other organizations, copies of other letters sent to CMS, and additional state-by-state information. Additionally, the Kaiser Family Foundation released a review of research​ on previous Medicare-Medicaid integration efforts and found little evidence of cost savings at the levels currently predicted by states and the federal government.

State-by-State Duals Data

The Kaiser Family Foundation maintains robust state-by-state data on elements such as the number of Medicare-Medicaid eligibles by state, spending, and managed care enrollment.  To learn more about your state’s Medicare-Medicaid eligible population, click here