BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY

INTEGRATED COVERAGE AND CARE EXPERIENCE FOR

Page 1 INDIVIDUALS WHO ARE DUAL ELIGIBLE

POLICY BRIEF:

Beneficiary Protections Central

to a Meaningfully Integrated
Coverage and Care Experience for
Individuals Who Are Dual Eligible
May 2023

Page 2
Introduction
Although 12.5 million Americans are
enrolled in both Medicare and Medicaid
(individuals who are dual eligible), the
two programs were not designed to
work together. This means that while
individuals who are dual eligible experience
some of the most significant clinical,
social, and care coordination needs,
these individuals, their families, and their
providers often must navigate complex
programs and policies that are fragmented
and at times in conflict. This program
and policy misalignment inhibits access
to appropriate, person-centered care for
individuals who are dual eligible.
With support from Arnold Ventures, ATI
Advisory (ATI) conducted listening sessions,
focus groups, and interviews with diverse
stakeholders to better understand the unique
needs and experiences of individuals who
are dual eligible for Medicare and Medicaid,
and their caregivers.1 Through these
conversations, ATI gained insights on the
potential role that integrated coverage and
care experiences can play in addressing the
concerns of individuals who are dual eligible
and their caregivers. Central to what we
heard is that individuals who are dual eligible
and their caregivers seek a person-centered
and seamless consumer experience.
1 For more information on the content and planning of these discussions, please see the Methods section.
BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
INDIVIDUALS WHO ARE DUAL ELIGIBLE
In this document, we include specific
comments from individuals who are dual
eligible and their caregivers, and where
12.5M
Americans
available, have identified policy and program
Enrolled in both
considerations responsive to the feedback
Medicare and
we heard. Some considerations, particularly
Medicaid
those related to accountability and oversight,
were not directly discussed in listening
sessions with individuals who are dual
eligible, their caregivers, providers, and other
key stakeholders; however, these protections
remain vital to ensure that individuals’ who
are dual eligible and/or their caregivers’
experience in coverage and care is as
seamless and accessible as possible. Below,
we have included beneficiary protections
specific to the following domains:
→ Eligibility
→ Enrollment Support
→ Care Navigation and Coordination
→ Covered Benefits
→ Provider Network
→ Consumer Advisory Boards
→ Unified Operational Processes
→ Oversight and Accountability

Page 3
Eligibility
WHAT WE HEARD:
Individuals who are dual eligible have
difficulty getting and maintaining
eligibility for Medicare and Medicaid
services.
Gaining and retaining Medicaid eligibility
can be a stressful experience for many
individuals. Medicaid eligibility requirements
should be no less than they are today, and
BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
INDIVIDUALS WHO ARE DUAL ELIGIBLE
“
ideally, would expand to provide access to
“You’re not
important services and supports for more
supposed to have
people. In addition, the process to retain
over $2,000 at all
eligibility should not be burdensome. For
for Medicaid, so like,
example, continuous Medicaid eligibility for a
how do you balance
certain amount of time can protect coverage
that between trying
between renewals, and having a deeming, or
to have somewhat
“grace,” period helps individuals resolve any
of a life and realize
temporary or administrative issues before
that you’re going
being removed from Medicaid coverage. As
to have some
an example best practice, states can auto-
expenses?”
verify eligibility using available information
and pre-populated forms when possible.

Page 4
Enrollment Support
WHAT WE HEARD:
Individuals who are dual eligible are
confused about their coverage options
and are unaware of the benefits of
enrolling in more integrated products.
Enrolling in different Medicare and Medicaid
programs can be a difficult and confusing
experience for individuals and their
caregivers. This is compounded by Medicare
and Medicaid processes and timelines that
often conflict. Individuals who are dual
eligible need a more simplified enrollment
experience that is culturally appropriate and
accessible. This simplification includes a
streamlined process, enhanced enrollment
support, and assurances that marketing and
available options are not misleading.
→ A Streamlined Enrollment Process.
Enrollment dates and materials vary
across Medicare and Medicaid. A
streamlined enrollment process would
result in a single, integrated experience
for individuals who are dual eligible, with
aligned dates, materials, and related
notifications.
→ Enhanced Enrollment Support.
There are many ways an individual
who is dual eligible can make program
enrollment decisions, but these are
often Medicare-only or Medicaid-
only decisions, and do not reflect full
coverage needs. Individuals who are dual
BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
INDIVIDUALS WHO ARE DUAL ELIGIBLE
eligible would benefit from enhanced
enrollment support that is impartial and “
culturally appropriate to help them in “Is there a Medicaid
their decision making, and reflective book? A Medicaid
of both their Medicare and Medicaid book of coverage?
coverage. In addition, individuals who Why don’t they
are dual eligible and their caregivers have a book for
need sufficient support, education, and that? That would
resources to ensure they are making be helpful… There’s
informed choices. This should include tons of different
access to a non-biased person that programs, tons of
can be seen as a trusted partner in the different data, and
enrollment decision making process and it’s not nicely laid
is educated on the value of integrated out.”
coverage. Online plan choice tools like
Medicare Plan Finder should also clarify
integration options, since individuals who
are dual eligible often must sift through
pages of plan choices with no clear
indication whether a plan is integrated
with Medicaid.
→ Assurances Against Misleading
Practices. Incentives may not always
align with helping a dual eligible
individual choose an integrated product.
For example, insurance brokers might
be commissioned differently for helping
an individual enroll into a non-integrated
product, or an organization might be
incentivized to offer a non-integrated
product. This can be confusing to dual
eligible individuals and their caregivers,
and assurances that incentives are
aligned with helping a person choose an
integrated product are important.
 BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
Page 5 INDIVIDUALS WHO ARE DUAL ELIGIBLE

Care Navigation and Coordination

distinct programs. In some instances, an “

WHAT WE HEARD:
Individuals who are dual eligible are
confused about how to access their
coverage across two programs and
need help navigating the health care
system. They described being unsure
of where to turn for help and wished
for “one place to go” for information
and guidance.
Individuals who are dual eligible often have
different sets of benefits across Medicare
and Medicaid, and these benefits may
conflict, may be redundant, or may need
to work together despite being from two
individual who is dual eligible might not know
“I would hang up
the benefits they are eligible for. Access to
[from calling the
appropriate and tailored benefits across
insurance company]
both programs is critical for individuals
and I would have
who are dual eligible, and navigating and
a lot of notes. And
coordinating care effectively requires
I’m sort of like, well,
multiple components. The importance of a
what’s the next
care navigator and team that can support
step?”
an individual with achieving their care goals
was one of the most consistent pieces of
feedback individuals who are dual eligible and
their caregivers provided.
Individuals who are dual eligible need
a more simplified experience when
navigating their benefits across both
Medicare and Medicaid programs.

This includes:

Principles What this means for the individual

The individual should access both Medicare and Medicaid

Simplified member benefits from the same place. This means having only one
experience member identification card, one set of member materials, and
one clearly identified point of contact.

The process of navigating care across two programs is often

confusing for individuals. Having a care navigator as a primary
point of contact can help individuals access and coordinate
care across all services, and support a person-centered care
Support navigating experience. The care navigator should have the right skills and
care experience coupled with autonomy from monied interests to be
an effective advocate for the people they are serving, including
through the prior authorization and appeals process. The
individual’s satisfaction levels and how well their goals are met
should impact the care navigator’s success metrics.
 BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
Page 6 INDIVIDUALS WHO ARE DUAL ELIGIBLE

Principles What this means for the individual

Having a comprehensive care plan in place ensures individuals

receive care tailored to their needs and preferences. To achieve
this, the individual should have full insight into their own care plan
and be able to request that it be conducted or revised whenever
they want. The care plan should cover all of the individual’s needs
Standardized,
including medical, functional, behavioral, social, and caregiving
comprehensive
needs, as well as their care preferences. The care navigator is
assessment and
a key partner in the care plan process and needs access to the
care planning
care and medical management systems for all individuals they
represent. The individual or their authorized caregiver should sign
off and agree to the care plan. The care plan should be revisited
on a regular basis, including at points of important transitions
(e.g., hospitalization).

When structured well, ICTs can be a powerful tool to help

coordinate quality care for individuals. All individuals should
have access to an ICT that is flexible and tailored to the needs
of the individual, which may vary significantly person to person
given that the dual-eligible population is very heterogenous. The
Interdisciplinary individual and/or their caregiver should have the option to help
care team (ICT) for determine who is on their care team, be involved in all care team
all individuals decisions, have a single point of contact to access their team,
and have equal decision-making power to other team members.
The care team should contribute to the comprehensive care plan,
be responsive to the evolving needs of the individual, and involve
long-term services and supports or behavioral health specialists
as needed.

The person-centered goals of the individual, which may include a

desire to return to or remain in the community and quality of life
improvements, should be supported. Screenings can identify any
A strategy
challenges to community-living that may need to be addressed,
to advance
and benefits, provider relationships, and the care model approach
community-living
should encourage community living. The ICT can connect the
goals
individual to peer supports and additional family supports if
desired to enforce a strengths-based approach to living in the
community.

Currently, individuals’ records are scattered across different

programs, which makes streamlined care difficult. The
Integrated
individual’s total services, care, and health history should be
systems
integrated in a centralized care management platform to promote
efficiency and thorough record keeping.
 BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
Page 7 INDIVIDUALS WHO ARE DUAL ELIGIBLE

Covered Benefits

This means: “
WHAT WE HEARD:
→ Covered benefits should be no less “There’s a lot of
It is difficult for individuals who are than they are today, and ideally states people that, you
dual eligible to access and understand and plans would seek to expand access know, they don’t
available benefits, in particular across medical, pharmacy, home and understand the
personal care services, transportation, community-based services (HCBS), non- difference between
accessibility modifications, and medical supports, and health-related assisted living,
appropriate medical equipment. social needs benefits. nursing homes, and
they don’t know
→ Individuals should be able to access what they qualify
benefits in a reasonable amount of time. for, or what they will
Individuals who are dual eligible have needs be able to access.
that span medical services often covered → Benefit design should be flexible and
And they aren’t even
by Medicare and non-medical supports and meet the individuals’ needs, regardless
sure what it is.”
services often covered by Medicaid. In some of whether those benefits are paid
instances, both programs cover a service for by Medicare or Medicaid, and
and an individual who is dual eligible or their should allow for value-add or other
provider must navigate program coverage or supplemental services that help to
rules. In other instances, Medicaid services serve the whole person.
prevent Medicare spending, or vice versa.
→ Individuals’ needs, including quality
An individual who is dual eligible’s covered
of life, should inform the benefits,
benefits should reflect the whole of these
services, and supports that a person
needs and circumstances, and misaligned
is connected with.
financial incentives to shift across services
and payers should be eliminated.

Page 8
Provider Network
WHAT WE HEARD:
Individuals who are dual eligible have
difficulty accessing providers because
directories are out-of-date and/or
listed providers are not accepting
new patients. Individuals who are dual
eligible and have a provider prioritize
access to their doctors when making
plan choices, as finding a new doctor
and developing a relationship with them
is both challenging and burdensome.
Finding and accessing providers can be
challenging for individuals who are dual
eligible and have to navigate complicated
and often different provider networks across
Medicare and Medicaid. Individuals who are
dual eligible need a comprehensive network
of medical and non-medical providers with
capacity to address physical, behavioral, and
social needs in a timely manner, recognizing
the diversity in need amongst the dual-
eligible population.
→ Providers should accept both Medicare
and Medicaid when serving the dual-
eligible population, and when it is
appropriate to the service. It can
be stressful for individuals who are
dual eligible to access providers who
only accept “part” of the individual’s
insurance coverage.
BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
INDIVIDUALS WHO ARE DUAL ELIGIBLE
→ Provider networks should be regularly “
monitored to ensure individuals who are
“If I change plans
dual eligible have continued sufficient
am I going to have
access to all covered services and
to go to a new
supports they are eligible for.
doctor? And it’s
→ Providers need support to build capacity like a hard thing
and meet the needs of the population here that I have to
they are serving. This is especially true explain everything
for the dual eligible population that tends because I have
to have complex and unique arthritis, I have high
circumstances, like having informal blood pressure, I’m
support systems, experiencing language paralyzed. But if I
barriers, or having intersecting medical get anybody new, I
and disability needs. Providers should be have to go through
trained in culturally competent, the whole notion
accessible, and person-centered care. all over again. And
you get tired of the
→ An individual who is dual eligible’s same thing over and
relationship with some providers is often over again.”
personal and can have a strong impact
on the individual’s well-being. For
example, an individual who is dual eligible
may have an established and trusted
relationship with a homecare provider or
personal care aide who visits the dual
eligible individual in their home. For this
reason, continuity of care transition
periods are essential, especially when
there could be any changes to their
coverage or enrollment in new programs.

Page 9
Consumer Advisory Boards
Individuals who are dual eligible should have
a voice in the design and launch of any model
that aims to integrate their Medicare and
Medicaid coverage. And once implemented,
individuals who are dual eligible should
continue to have opportunities to provide
input and feedback on their coverage. For
example, Consumer Advisory Boards can be
an important tool to ensure that individuals
have that voice in the way their care and
coverage is delivered. Feedback from
individuals and their caregivers impacted
by the changes needs to be requested as
new programs related to their Medicare and
Medicaid coverage are being designed and
then on an ongoing basis.
The dual eligible population is heterogenous,
and it is important that there is
representation from all of the impacted
community, including by geography, race,
BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
INDIVIDUALS WHO ARE DUAL ELIGIBLE
ethnicity, language, age, gender, LGBTQ+
status, and disability. In addition, given the
range of needs and abilities among dual
eligible individuals and their caregivers, it is
important that Consumer Advisory Boards
are accessible. This includes: Consumer
Advisory Boards
→ Language accommodations
can be an
→ Transportation services important tool
to ensure that
→ Child or elder care individuals have
a voice.
→ Disability accommodations for
individuals with both physical and/
or intellectual and/or developmental
disabilities (I/DD)
→ Training in effective committee
participation, including time and support
to prepare and understand information
→ Financial compensation

Page 10
Unified Operational Processes
Individuals have the right to file appeals and
grievances to elevate concerns about their
care or challenge a coverage decision. For
those who are dual eligible, this has usually
meant having to navigate two separate
systems for both Medicare and Medicaid,
depending on the issue. Because individuals
who are dual eligible and their providers often
confuse the two insurers, this navigation can
be difficult. Filing appeals and grievances,
Oversight and Accountability
PUBLIC HEARINGS ON PROGRAM
DEVELOPMENT AND DESIGN
Public hearings are an important part of
program development and design because
they allow the individuals who will be
impacted by the program to provide input,
as well as other impacted stakeholders.
Hearings regarding Medicare-Medicaid
integrated program design should be
inclusive of individuals who are dual
eligible, their providers, and other impacted
stakeholders. In addition, stakeholders –
including individuals who are dual eligible
– should also have access to a user-friendly,
accessible, public website that is updated
regularly with the progress and status of
design efforts.
REQUIRED OMBUDSMAN PROGRAM
Ombudsman programs are critical for helping
individuals with Medicaid eligibility or with
long-term services and supports needs, and
BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
INDIVIDUALS WHO ARE DUAL ELIGIBLE
regardless of whether they are for the
Medicare or Medicaid program, should be a
fully integrated process for individuals who
are dually eligible and their providers, and
they should be provided with reasonable
levels of support in completing any forms and
moving through the necessary steps.
these programs were important in ensuring
beneficiary protections as part of the
Financial Alignment Initiative demonstrations
conducted through the Centers for Medicare
and Medicaid Innovation. An ombudsman
program should provide individual assistance,
systemic monitoring and reporting, and
consumer education and empowerment,
and should be available to all individuals
who are dual eligible. Because of their
role, ombudsman programs should have
independence, expertise, and sufficient
resources to assist individuals who are dual
eligible. The program should also coordinate
with other aging and disability network
providers in the state to ensure individuals
who are dual eligible receive comprehensive
and efficient support. Coordination with
the current state and federal beneficiary
protection services is equally as important,
and this includes Managed Care Beneficiary
Support Systems, Long-Term Care
Ombudsman Programs, and Disability
Protection and Advocacy Programs.
 BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
Page 11 INDIVIDUALS WHO ARE DUAL ELIGIBLE

DATA ANALYSIS, REPORTING, AND data collection and reporting. For example,
TRANSPARENCY barriers to community-living should be
tracked and reported for individuals living
Data reporting, collection, and analysis are
in institutions. Reported data should be
key to understanding care experiences and
disaggregated to show needs and gaps in
outcomes, and to help inform improvements
care by population, and at minimum should
for the dual eligible population. The right data
be collected across the following: race,
can improve quality of care, ensure access
ethnicity, sexual orientation, gender identity,
to community-based services, and advance
age, language preference, disability status,
health equity. However, most of the data on
and geographic location. Data should also be
Medicare-Medicaid integrated programs
used to develop tailored programming and
and for long-term services and supports
inform person-centered care planning, and
that exist today are incomplete and often
when appropriate, should be accessible to
lack sufficient detail to truly understand
the public.
program or service impacts. There need to
be clear processes and protocols to support
 BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
Page 12 INDIVIDUALS WHO ARE DUAL ELIGIBLE

In Summary: A Commitment
to Independent Living and
Person-Centered Experiences

The protections described in this report reflect first-hand experiences and preferences of
individuals who are dual eligible and their caregivers, identified through a series of listening
sessions, focus groups, and interviews. In summary, individuals are seeking a simplified and
person-centered experience that supports their ability to live independently, and in response
to that feedback, there are specific protections that can be incorporated into any efforts to
integrated Medicare and Medicaid to enable this simplified and person-centered experience.

Medicare-Medicaid integrated program protections should reflect the diverse population of

individuals who are dual eligible, including those with physical disabilities, older adults, those
with behavioral health needs, and people with I/DD. Key themes include the following:

D Robust and appropriate HCBS should D Provider networks should be integrated

be available to people who need them. and reflect the comprehensive needs
of dual eligible individuals.
D Care navigation and care planning
should consider the individual’s D Data reporting should be robust and
preferences and goals related to standardized to enable consistent
returning to or remaining in the data analysis that informs program
community. improvements. Data should also
be disaggregated to provide a
D Individuals should have access to comprehensive understanding of the
services that support whole-person population and ensure well-informed
care.
person-centered care.
D Covered benefits should be tailored to
the needs of individuals, regardless of
whether Medicare or Medicaid pays for
the benefit, and they should allow for
additional services to better serve the
whole person.

Page 13
Methods
ATI Advisory conducted focus groups with
53 individuals who are dual eligible and/or
their caregivers. This included focus groups
conducted in English and in Spanish. Focus
groups were recorded and transcribed using
software to ensure fidelity to consumer
feedback. ATI also conducted structured
interviews with 44 stakeholders and
providers encompassing consumer advocacy
organizations, state agency officials,
BENEFICIARY PROTECTIONS CENTRAL TO A MEANINGFULLY
INTEGRATED COVERAGE AND CARE EXPERIENCE FOR
INDIVIDUALS WHO ARE DUAL ELIGIBLE
academics and researchers, and direct care
workers. Interviews were conducted using
a semi-structured interview guide, with key
questions and prompts, but with flexibility for
interviewees to provide feedback on topics
of most importance and relevance to them.
Focus group findings and interview notes
were collated into an Excel database and
were analyzed thematically using the topics
outlined above.
About ATI Advisory
ATI Advisory is a healthcare research and advisory services firm advancing innovation that
fundamentally transforms the care experience for individuals, families, and communities. ATI
guides public and private leaders in successfully scaling healthcare innovations. Its nationally
recognized experts apply the highest standards in research and advisory services along with deep
expertise to generate new ideas, solve hard problems, and reduce uncertainty in a rapidly changing
healthcare landscape. For more information, visit www.atiadvisory.com.

Arnold Ventures is a philanthropy working to improve the lives of all Americans by pursuing
evidence-based solutions to our nation’s most pressing problems. Arnold Ventures funds research
to better understand the root causes of broken systems that limit opportunity and create injustice.
Its focus areas include Criminal Justice, Higher Education, Health, and Public Finance. In each area,
Arnold Ventures advocates for policy reforms that will lead to lasting, scalable change.