Expanding Health Care Coverage


Mathematica Policy Research

Funding Area

Expanding Health Care Coverage


February 1, 2012


This NYHealth-funded report by Mathematica Policy Research provides specific recommendations for New York State as it works to improve the coordination and integration of care dual eligibles receive through Medicare and Medicaid.

More than 700,000 people in New York are simultaneously enrolled in both Medicare and Medicaid. These “dual eligibles” are among New York State’s costliest and most complex Medicaid beneficiaries. Because they have greater care needs than the average Medicaid enrollee, dual eligibles often require a complex array of services from multiple providers. Managed care organizations have limited experience in serving this population, and dual eligibles themselves are concerned about potential restrictions to provider access under managed care. However, developments at both the Federal and State levels provide opportunities to better coordinate care for this costly and complex population. The report provides a comprehensive profile of:

  • Dual eligible characteristics, care needs, costs and service delivery options.
  • Aspects of New York’s Medicaid program that present opportunities and challenges for integrated care programs for dual eligibles.
  • Integrated care program design options based on a review of programs in other states, the characteristics and care needs of dual eligibles in New York State, and feasible options based on State capabilities and potential for Federal approval.

Key recommendations include:

  • Use the Federal dual eligible demonstration to support and enhance State initiatives for dual eligibles.
  • Require greater integration of all Medicaid and Medicare services in capitated managed care programs.
  • Use the CMS financial alignment models to help finance more integrated benefits for dual eligibles.
  • Use three-way capitated contracts to broaden and integrate the benefit package for dual eligibles.
  • Use passive enrollment to increase enrollment in the dual eligible demonstration.