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Dual Eligible Advocacy: A Key Social Determinant of Health Service

Social Determinants of Health (SDOH) are all the talk in managed care now. Behind all the buzz, is the big question — how do we understand and impact SDOH?

Understanding SDOH starts with engaging Medicare Advantage members in conversation, and impacting SDOH is about linking them with select benefits and services. For low-income seniors there is, perhaps, no more meaningful help than financial assistance — like Medicaid and the Medicare Savings Programs. Since lower income members have historically had higher healthcare expenditures, appropriate classification of these members as “Dual Enrolled” in Medicaid or the Medicare Savings Programs can result in a substantial capitation increase for Medicare Advantage plans.

Medicare Advantage Organizations (MAOs) have done Dual Eligible Outreach and Advocacy for over twenty years, but there is still work to be done — as evidenced by the low Dual penetration rates in many health plans.

So What is Dual Eligible Outreach and Advocacy?

The Programs There are a variety of Medicaid programs for which Medicare recipients might be eligible. Those programs are grouped into two categories: Full Medicaid and Partial Medicaid. These distinctions are important because there is a difference in the benefits the member receives, and in the capitation paid to the plan.

Full Medicaid: Medicaid generally pays premiums for Part A (if any) and Part B, as well as cost sharing for Medicare services. Member receives full Medicaid benefits. • Full Medicaid • Qualified Medicare Beneficiary Plus (QMB Plus) • Specified Low-income Medicare Beneficiary Plus (SLMB Plus)

Partial Medicaid • Qualified Medicare Beneficiary (QMB): Medicaid generally pays premiums for Part A (if any) and Part B, as well as cost sharing for Medicare service • Specified Low-income Medicare Beneficiary (SLMB): Medicaid plays Part B premiums. • Qualified Individual (QI): Medicaid pays Part B premiums. • Medicaid Spend Down (while many members might qualify for this program, the ongoing documentation for eligibility is difficult for many of our MA members)

The Opportunity Despite the valuable benefits of enrollment, the majority of Medicare members who are eligible for Medicaid programs are not enrolled in those programs (see graphic below). Participation rates vary by geography and a host of other factors but the largest barrier to enrollment is a lack awareness of the programs and their benefits. Members who are likely to qualify for a Medicaid program (including the Medicare Savings Programs) have a variety of predictive characteristics which a predictive algorithm can identify. A robust outreach program, casting a wide net, can engage members who are eligible but not enrolled. Once these members are engaged, a professional advocate (like the wonderful advocates we have at BeneLynk) can guide the members through the application process to secure the benefits they deserve.

What New Medicaid/MSP Enrollment Means for the Member Specific Medicaid benefits vary by program, but for all the Full and Partial Dual benefit programs, enrollment means the state pays the member’s Medicare Part B premium. The standard Medicare Part B monthly premium is currently $135.50 per month. For an individual at 100% of FPL ($16,460 annually) this $1,626 annually represents a 10% increase in available money. In other words, enrollment in Medicaid benefits has a powerful, positive impact on low-income Medicare members!

What New Medicaid/MSP Enrollment Means for the Medicare Advantage Plan A robust Dual Eligible outreach program first and foremost allows Medicare Advantage plans to deliver a meaningful service to some of their most vulnerable members. It allows MAOs to comply with CMS guidance outlined in Chapter 4 of the Medicare Managed Care Manual. And it ensures that the MAOs receive appropriate capitation increases for the members who are now correctly categorized as Dual enrolled. CMS has also recently encouraged states to do more for beneficiaries by making enrollment and recertification easier.

Helping your members get valuable benefits can make a real impact in their lives, and ensure that you receive appropriate capitation for low-income members. Despite years of outreach and advocacy services, the participation rate in these programs remains far too low. To get your members these benefits, you need a vendor-partner with a robust outreach and advocacy program — a partner committed to engaging as many of your members as possible.

About the Author Sean Libby has been an advocate for seniors, people with disabilities, veterans, and individuals with low income for over 17 years. At BeneLynk, we are committed to helping managed care plans to deliver superior Social Determinant of Health solutions to their members. We are always looking to learn more and would like to hear your ideas on how best to assist members in need. Drop us a note at

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