1. Dual eligible beneficiaries comprise 20% of the
Medicare population and 15% of the Medicaid
population in 2008
Medicare Dual Eligible Medicaid
37 million Beneficiaries 51 million
9 million
Total Medicare beneficiaries: 46 million Total Medicaid beneficiaries: 60 million
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey 2008, and Kaiser Commission on Medicaid and the
Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.

2. Medicare is the primary payer of medical care
for dual eligible beneficiaries
Distribution of Medicare Spending for Dual
Eligible Beneficiaries in Medicare FFS by
Medicare Service, 2008
• National program for Inpatient
individuals age 65+ and Hospital
younger adults with
disabilities (on SSDI) Hospice 34%
4%
• Eligibility tied to work Home
history but not tied to Health 5%
income or health status Providers
• Covers medical care, 20%
SNF 8%
prescription drugs, and is
the primary source of
Drug
medical insurance for dual Subsidies
13%
eligible beneficiaries
Outpatient 16%
• Financial obligations can
be steep for beneficiaries
Average Per Capita Medicare FFS Spending:
$13,805
NOTE: Medicare Advantage spending excluded from this analysis.
SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008

3. Medicaid supplements Medicare for
dual eligible beneficiaries
Distribution of Medicaid Spending
for Dual Eligible Beneficiaries by
Service, 2008
Medicaid
Medicare
• Federal-state partnership premiums
with states operating
9%
programs for low-income
69%
families, disabled &
elderly Long Term Medicare
• Eligibility tied to income, Care acute care
age and disability, varies 16% cost-
by state
sharing
• Pays for Medicare
premiums, cost-sharing 5% Acute care
and other benefits not covered
by Medicare
• Primary payer for long- 1%
term care Prescription
Drugs
Average Per Capita Medicaid Spending:
$16,087
NOTES: Home health and dental services comprise less than 1% of Medicaid spending. Medicare premiums paid by Medicaid also includes cost-
sharing for Qualified Medicare Beneficiaries only.
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.

4. Dual eligible beneficiaries are a diverse
population
Age 85+
4 or more
14%
Chronic
Age 75-84 No Mental Conditions
Impairments 35%
21%
51%
Community 3 Chronic
Age 65-74 Conditions
87%
26% 20%
2 Chronic
Conditions
Mental
20%
Under Age 65 Impairment 0 or 1
39% 49% Chronic
Facility Conditions
13% 25%
Age Type of Mental Number of
Residence Impairments Chronic
Conditions
NOTE: Mental impairments were defined as Alzheimer’s disease, dementia, depression, bipolar, schizophrenia, or mental retardation.
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey, 2008

5. Dual eligible beneficiaries are poorer than
other Medicare beneficiaries
Share of Medicare beneficiaries who are:
Income below 150% FPL 86%
(<$15,600 individuals/
<$21,000 couples) 22%
61%
Female
53%
Dual eligible
20% beneficiaries
African American
7% All other Medicare
beneficiaries
17%
Hispanic
6%
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.

6. Dual eligible beneficiaries are sicker than
other Medicare beneficiaries
Share of Medicare beneficiaries with:
Cognitively or 58%
Mentally Impaired
25%
55%
3+ Chronic Conditions
44%
50%
In Fair or Poor Health
22%
Dual eligible
beneficiaries
44%
Functionally Impaired All other Medicare
26% beneficiaries
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.

7. Dual eligible beneficiaries use more health
services
Share of Medicare beneficiaries with:
26%
1+ Hospital Stay
18%
1+ Emergency 17%
Room Visit
12%
Dual eligible
1+ Skilled Nursing 9% beneficiaries
Facility Stay All other Medicare
4% beneficiaries
NOTE: Excludes Medicare Advantage enrollees.
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.

8. Dual eligible beneficiaries account for a
disproportionate share of Medicare and Medicaid
spending, 2008
Dual Eligible Beneficiaries as a Share Dual Eligible Beneficiaries as a Share
of Medicare Population and Spending of Medicaid Population and Spending
61%
69%
80% 85%
39%
31%
20% 15%
Total Population: Total Spending: Total Population: Total Spending:
46 Million $424 Billion 60 Million $330 Billion
Medicare Medicaid
SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost and Use File, 2008, and Kaiser Commission on
Medicaid and the Uninsured and Urban Institute estimates based on data from FY2008 MSIS and CMS Form-64.

9. Medicare spending was more than $40,000 for
8% and less than $2,500 for 16% of the dual
eligible population
Distribution of Medicare
spending for Dual Eligible
Beneficiaries, 2008:
$15,000-
$20,000
$10,000-
$15,000
13%
$5,000-$10,000
26%
Average Spending = $14,169
Median Spending = $7,036
SOURCE: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey Cost & Use File, 2008.

10. Dual eligible beneficiaries account for a
substantial share of Medicaid spending
Medicaid Enrollment, 2009 Medicaid Spending, 2009
Premiums
3%
Medicare
Acute 7%
Other
Adults Aged & Other Acute
26% Other Aged Disabled 2%
& Disabled Spending
10% 28%
Duals Duals
15% Long- Spending
Children Term Care 38%
Children & Adult 25%
49% Spending
34%
Prescribed
Drugs 0.4%
Total = 63 Million Total = $359 Billion
SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012. MSIS FY
2008 data were used for MA, PA, UT, and WI, but adjusted to 2009 CMS-64.

11. Few dual eligible beneficiaries are high spenders
under both Medicare and Medicaid
0.8
0.1 Top 10% of Medicare
0.8 $80.8 Spenders; Spending Above
$44,348
$12.3 Top 10% of Spenders in Both
Medicare and Medicaid
$67.8
Top 10% of Medicaid
Spenders; Spending Above
7.2
$45,180
Not a Top 10% Spender in
Either Program
$104.8
Total Beneficiaries= 8.9 million Total Spending= $265.7 billion
SOURCE: KCMU/ Urban Institute analysis of MSIS-MCBS 2007.

12. Spending by service varies among high-cost dual
eligible beneficiaries by program
Top 10% Medicare Spenders Top 10% Medicaid Spenders
(in billions) (in billions)
Long-Term
Care, $8.3
9%
Sub-Acute Acute
Care, $11.7
Care,
13%
$18.4
23%
Sub-
Acute
Long- Care, $2.8
Acute Care, Term 4%
$73.1 Care,
78% $58.9
74%
Total = $93.1 billion Total = $80.1 billion
NOTE: Top 10% Medicare spenders = Medicare spending greater than $44,348, includes Medicaid spending on Medicare high-spenders.
Top 10% Medicaid spenders = Medicaid spending greater than $45,180, includes Medicare spending on Medicaid high-spenders.
SOURCE: KCMU/Urban Institute analysis of MSIS-MCBS 2007.

13. Share of Dual Eligible Beneficiaries in Medicare
Advantage and Medicaid Managed Care Plans,
2000-2008
Share of Duals in Medicare Advantage Plans
Share of Duals in Comprehensive Medicaid Managed Care Plans
20%
17%
14%
9% 10% 9%
9% 9%
7% 8%
7% 7% 7%
6%
2000 2001 2002 2003 2004 2005 2006 2007 2008
NOTES: Data exclude dual eligibles living in Puerto Rico and other territories. Medicaid manage care data include duals in commercial and
Medicaid managed care organizations (comprehensive risk), health insuring organizations, and PACE plans. Information on dual enrollment in
Medicaid comprehensive managed care plans was not available at the time of publication for years prior to 2004.
SOURCE: Gold M., Jacobson G, and Garfield R. analysis of the CMS MCBS Cost and Use File, 2000-2008, CMS Medicaid Managed Care Enrollment
reports, 2004-2008, and Medicaid Statistical Information System 2004-2008., Health Affairs 2012.

14. Share of Dual Eligible Beneficiaries
Enrolled in Managed Care, by State, 2010
NOTE: National average was 12.0% enrolled in Medicare Dual-Special Needs Plan (DSNP )and 9.3% enrolled in comprehensive Medicaid managed
care (MMC. )
SOURCE: Gold M, Jacobson G, and Garfield R. analysis of public Medicare and Medicaid data files from the Center for Medicare and Medicaid
Services, Health Affairs, 2012.

15. 26 states are moving forward with proposals to
participate in demonstration projects, May 2012
WA VT ME
MT ND NH
MN
OR WI NY MA
ID SD MI
WY CT*RI
PA NJ
IA*
NE OH DE
NV IL IN MD
UT WV VA
CO* MO* DC
KS KY
CA
NC*
TN
OK* AR SC
AZ NM
MS AL GA
TX LA
FL
AK
HI
Proposed 2013 Start Date (14 states)
Proposed 2014 Start Date (12 states)
Not participating in demonstration (24 states
and DC)
* CO, CT, IA, MO, NC, and OK are proposing managed FFS models. All others have proposed capitated models.
NOTE: MO has proposed a 2012 start date.
SOURCE: Correspondence with CMS Medicare-Medicaid Coordination Office, May 2012

16. Key considerations for testing new models of
managed care for dual eligible beneficiaries
• The current landscape offers room for improvement
The current system is fragmented; coordination will help to improve care
• One size will not fit all
Various approaches are needed to address each subgroup’s unique needs
• Building expertise and plan capacity takes time
Few health plans and states have experience managing both populations
• Proceed with caution
Infrastructure needs to be in place; transitions are difficult
• Don’t count your savings before they are hatched
Many are laying claim to savings, few results to date have shown cost savings
• Accountability matters: who will be in charge?
Oversight needs to protect beneficiary rights and evaluation needs to be dynamic
SOURCE: Dx For A Careful Approach To Moving Dual Eligible Beneficiaries Into Managed Care Plans. Health Affairs, June 2012.
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