What Are the Primary Medicaid Eligibility Pathways for Dual-Eligible Individuals?

In 2021, 1 in 5 Medicare beneficiaries or 13.1 million folks, generally known as “dual-eligible people,” had each Medicare and Medicaid protection. Eligibility for Medicare, which is the first supply of protection for dual-eligible people, is predicated on their age or incapacity standing. For many dual-eligible people, there are two pathways to Medicaid eligibility: one is thru Medicaid eligibility pathways for seniors and folks with disabilities and the opposite is thru the Medicare Financial savings Applications. These eligibility pathways confer completely different advantages. The Medicaid eligibility pathways present protection of Medicaid advantages that aren’t in any other case coated by Medicare together with long-term providers and helps (LTSS), imaginative and prescient, and dental care. The Medicare Financial savings Applications cowl Medicare premiums and sometimes, value sharing, however not Medicaid advantages. Medicare beneficiaries who’re solely eligible for Medicaid by way of the Medicare Financial savings Applications are “partial-benefit” dual-eligible people as a result of they solely obtain protection of Medicare premiums and sometimes, value sharing. To be a “full-benefit” dual-eligible particular person, Medicare beneficiaries have to be enrolled in Medicaid by way of a Medicaid eligibility pathway past the Medicare Financial savings Applications. (Most full-benefit dual-eligible people are eligible for each.)

Federal statutes require states to enroll individuals who obtain Supplemental Safety Earnings (SSI) in Medicaid and to enroll eligible Medicare beneficiaries within the Medicare Financial savings Applications. Past these two “necessary” eligibility pathways, there are elective Medicaid eligibility pathways that states might select to supply for individuals who have disabilities or are ages 65 and older, together with choices to develop protection past what’s required underneath federal regulation to low-income seniors and folks with disabilities; protection for “medically needy” people who qualify for Medicaid after deducting incurred medical bills from their earnings; and protection for individuals who want LTSS.

States are presently implementing new guidelines designed to streamline the enrollment and renewal programs for the Medicare Financial savings Applications and for Medicaid. The foundations are supposed to assist eligible people acquire and keep Medicaid protection by decreasing administrative burdens on candidates and enrollees. As the brand new necessities begin to take impact, this transient examines present Medicaid eligibility insurance policies and enrollment patterns utilizing knowledge from KFF’s 2024 50-state survey of states’ eligibility and enrollment insurance policies for seniors and folks with disabilities, and 2021 Medicare and Medicaid claims knowledge from the Facilities for Medicare and Medicaid Companies (CMS).

Key Takeaways

Many of the 13.1 million dual-eligible people are enrolled in Medicaid by way of necessary eligibility pathways: 4.6 million by way of SSI and 4.1 million by way of the Medicare Financial savings Applications. The remaining 4.5 million are enrolled by way of elective pathways (Determine 1).
Among the many 9.7 million dual-eligible people with full Medicaid, practically half (47%) are eligible by way of the one necessary pathway to full Medicaid, which is SSI.
Though it is just provided by 28 states, the following most typical pathway for full Medicaid is an elective pathway that gives protection for seniors and folks with disabilities who’ve earnings under the federal poverty degree, overlaying 14% of full-benefit dual-eligible people. Different elective pathways are provided by extra states however solely a small proportion of dual-eligible people enroll in every of these pathways (Determine 2).
Nearly all (92%) dual-eligible people with partial Medicaid (3.1 million) are eligible by way of the Medicare Financial savings Applications. Federal regulation defines minimal earnings and useful resource limits for every of the Medicare Financial savings Applications, however in 2024, 18 states reported having earnings and/or asset ranges above the federally required limits for the Medicare Financial savings Applications. These states are dwelling to 1.1 million or a 3rd (33%) of dual-eligible people with partial Medicaid.
As new federal necessities for enrolling folks within the Medicare Financial savings Applications take impact, most states report being in compliance with the necessities by October 2024.

KFF’s Survey of Medicaid Monetary Eligibility & Enrollment Insurance policies for Seniors & Folks with Disabilities, was performed by KFF and Watts Well being Coverage Consulting, and describes states’ eligibility and enrollment insurance policies for seniors and folks with disabilities as of June 2024. General, 49 states and the District of Columbia (hereafter known as a state) responded to the survey, although response charges to particular questions assorted (Florida was the one state that didn’t reply). Responses have been supplemented with publicly obtainable info and knowledge from KFF’s 2022 survey when obtainable.

The evaluation additionally makes use of merged beneficiary-level Medicare and Medicaid knowledge from 2021—the newest full launch of Medicaid knowledge—to investigate what number of dual-eligible beneficiaries enter Medicaid by way of every of the eligibility pathways. The enrollment evaluation consists of 13.1 million dual-eligible people in 2021 (see Strategies).

How do full-benefit dual-eligible people change into eligible for Medicaid?

Medicaid Eligibility Pathways for Seniors and Folks with Disabilities

To qualify for full Medicaid advantages, dual-eligible people should meet Medicaid eligibility standards, sometimes by way of eligibility pathways particular to folks ages 65 and older (seniors) and folks with disabilities (see Appendix). The Medicaid pathways wherein eligibility is predicated on previous age or incapacity are generally known as “non-MAGI” pathways as a result of they don’t use the Modified Adjusted Gross Earnings (MAGI) monetary methodology that applies to youngsters, pregnant people, mother and father, and different non-elderly adults with low incomes. (Medicare beneficiaries who’re eligible due to a incapacity might enroll in Medicaid by way of all MAGI pathways aside from the pathway for adults eligible by way of the Inexpensive Care Act, however extra usually qualify by way of disability-related pathways. Medicare beneficiaries who’re ages 65 and older are typically not eligible for Medicaid by way of the MAGI pathways.)

Along with contemplating earnings, non-MAGI Medicaid candidates should meet different eligibility necessities that make the appliance extra onerous than is the case for MAGI candidates. Non-MAGI candidates should meet eligibility necessities associated to their age or incapacity standing and except dwelling in a state that has eradicated asset limits, most candidates should exhibit that they’ve restricted financial savings and different monetary assets (e.g., belongings). Medicaid enrollees who use LTSS should additionally meet necessities associated to their practical wants that are typically measured by their skill to carry out actions of day by day dwelling similar to consuming and bathing. Past SSI (the one necessary pathway), the principle elective non-MAGI pathways to full Medicaid eligibility embrace state choices to develop protection to low-income seniors and folks with disabilities, “medically needy people” who qualify for Medicaid by deducting incurred medical bills from their earnings, and protection for individuals who use LTSS. Every group has completely different guidelines about earnings and belongings, making eligibility determinations complicated.

Most full-benefit dual-eligible people are additionally eligible for the Medicare Financial savings Applications, however eligibility for the Medicare Financial savings Applications doesn’t present entry to full Medicaid. To be a full-benefit dual-eligible particular person, folks enrolled within the Medicare Financial savings Applications should additionally meet the eligibility standards for one of many different Medicaid eligibility pathways, wherein case, they might be eligible for Medicaid by way of two mechanisms: whichever Medicaid pathway confers eligibility for full Medicaid and the Medicare Financial savings Applications (which cowl Medicare premiums and sometimes, value sharing).

Necessary eligibility by way of SSI

In 2021, 4.6 million full-benefit dual-eligible people have been enrolled in Medicaid by way of the one pathway that states are required to cowl, SSI (Determine 2). These enrollees comprised 47% of all full-benefit dual-eligible people. To be eligible for SSI, beneficiaries will need to have low incomes, restricted belongings, and both be older than 64 or have a qualifying incapacity. Though there’s a normal federal most profit, some states complement the federal profit with further funds. In these states, the SSI profit ranges—and relevant earnings limits for SSI recipients—are increased.

The proportion of full-benefit dual-eligible people enrolled in Medicaid by way of SSI assorted throughout states—from lower than 30% in 9 states to over 85% in Maine, Texas, and Missouri (Appendix Desk 2). Such variation displays variations within the SSI earnings restrict and the extent to which the states provide protection by way of elective Medicaid eligibility pathways along with the necessary SSI pathway, amongst different elements similar to incapacity charges, demographic traits, eligibility determinations, and knowledge high quality/availability.

Non-obligatory Medicaid eligibility pathways associated to earnings

A complete of two.2 million full-benefit twin eligible people are eligible for Medicaid by way of elective eligibility pathways for low-income seniors and folks with disabilities. A few of the extra distinguished choices embrace: “purchase in” packages for working folks with disabilities (obtainable in 49 states), medically needy protection (obtainable in 34 states), and protection for seniors and folks with disabilities with incomes above the SSI eligibility thresholds (obtainable in 28 states). The KFF survey didn’t embrace the purchase in packages in 2024, so states’ insurance policies come from the 2022 KFF survey.

The elective eligibility pathway that was provided by the fewest states enrolled the biggest variety of full-benefit dual-eligible people: low-income seniors and folks with disabilities, which coated 14% of full-benefit dual-eligible people (1.3 million folks). The pathway for low-income seniors and folks with disabilities is the best pathway administratively as a result of it solely requires details about folks’s earnings and usually, belongings. Most different non-MAGI eligibility pathways additionally require details about folks’s well being standing, practical standing, or spending on well being care. The share of full-benefit dual-eligible people eligible by way of the state choice to develop protection to low-income seniors and folks with disabilities was 14% nationally and ranged from lower than 1% in 33 states to over 40% in Hawaii, Massachusetts, and North Carolina (Appendix Desk 2).

Greater than 775,000 or 8% of full-benefit dual-eligible people have been enrolled in medically needy protection in 2021 (Determine 2). This pathway is likely one of the most complicated administratively as a result of persons are eligible if their earnings exceeds the restrict of one other pathway, however provided that they “spend down” to the medically needy restrict by deducting well being care bills from their earnings. The after-health care spending earnings limits are typically low—under 50% of the federal poverty degree in additional than half of the states providing such protection. There have been solely 4 states (Illinois, Maryland, New York, and North Dakota) wherein greater than 20% of full- profit dual-eligible people have been enrolled by way of medically needy pathways.

The Medicaid purchase in program refers to a number of Medicaid eligibility pathways that serve employees with disabilities who’re incomes earnings and for whom states might cost premiums as a situation of Medicaid eligibility, which mixed enrolled solely 2% of full-benefit dual-eligible people in 2021 (nearly 154,000 folks). Beneath the purchase ins, states cowl folks with disabilities who’re working, even when their earnings or belongings exceed the restrict for different eligibility pathways. This feature allows folks with disabilities to retain Medicaid’s protection of medical care and LTSS as their earnings will increase. Medicaid can fill in protection gaps for working folks with disabilities as a result of personal medical insurance sometimes doesn’t cowl all of the providers and helps that they should reside independently and work. Iowa was the one state wherein no less than 20% of full-benefit dual-eligible people have been enrolled by way of a purchase in.

Non-obligatory Medicaid eligibility pathways associated to LTSS

In 2024, 1.0 million folks have been eligible by way of a number of broadly adopted Medicaid eligibility pathways particular to folks utilizing LTSS who require an institutional degree of care (Determine 2, Appendix Desk 1). The 2 main eligibility pathways for folks utilizing LTSS embrace Katie Beckett protection for youngsters who’ve vital disabilities requiring an institutional degree of care however dwelling at dwelling (43 states) and the particular earnings rule, which covers different folks requiring an institutional degree of care with incomes as much as 300% of the SSI profit fee ($2,829 in 2024). General, 42 states provide protection by way of a particular earnings rule, with 41 states providing the choice to folks in establishments and 41 states providing the choice to folks dwelling at dwelling. Much less is understood about states’ different home- and community-based providers (HCBS) expansions, which embrace state-specific demonstration packages and people who find themselves eligible for Medicaid by way of the Program of All-Inclusive Look after the Aged. (KFF’s eligibility surveys excluded different HCBS expansions.) LTSS-related pathways are administratively complicated as a result of candidates should exhibit their want for an institutional degree of care. In consequence, individuals who could also be eligible for Medicaid by way of LTSS-related pathways and thru different pathways usually tend to be enrolled by way of these different pathways.

Though these elective Medicaid eligibility pathways associated to LTSS are adopted by most states, they collectively enrolled solely 11% of full-benefit dual-eligible people (1 million) in 2021 (Determine 2). Low enrollment in Katie Beckett displays the truth that there are few dual-eligible people underneath the age of 19. For the opposite three LTSS-related pathways, dual-eligible people comprise three quarters of all Medicaid enrollees (see Appendix). Throughout the states, the share of dual-eligible people enrolled in Medicaid by way of every of the LTSS-related pathways varies, with some states having over 20% of dual-eligible people enrolled in different HCBS expansions or a particular earnings rule program (Appendix Desk 2).

Different or Unknown Medicaid eligibility pathways

Roughly 1.9 million full-benefit dual-eligible people have been eligible for Medicaid by way of different or unknown Medicaid eligibility pathways, together with 0.9 million people who have been in states that recorded their eligibility within the administrative knowledge because the Medicare Financial savings Applications. Within the Medicaid administrative knowledge, enrollees obtain just one eligibility code every month; subsequently among the many full-benefit dual-eligible people within the Medicaid Financial savings Applications it’s unknown how these full-benefit dual-eligible people turned eligible for full Medicaid. The remaining 0.9 million full-benefit dual-eligible people have been in an “different” or “unknown” Medicaid eligibility group. These pathways included lacking values and values for the smaller eligibility teams, practically all of which correspond to eligibility for youngsters and fogeys. (Totals don’t add as much as 1.9 million as a result of rounding.) 

How do partial-benefit dual-eligible people change into eligible for Medicaid?

The Medicare Financial savings Applications

Twin-eligible people with partial Medicaid advantages don’t obtain protection of the total vary of Medicaid advantages, similar to long-term providers and helps, however do obtain funds of Medicare premiums and, usually, value sharing by way of the Medicare Financial savings Applications. Medicare beneficiaries are liable for cost of Medicare premiums, deductibles, and different value sharing necessities except they’ve supplemental protection, a Medicare Benefit plan that covers a few of the value sharing, or have incomes and belongings low sufficient to qualify for the Medicare Financial savings Applications (underneath which state Medicaid packages present help with Medicare Half A and Half B premiums and/or value sharing) and the Half D Low-Earnings Subsidy (LIS) (which helps with Medicare Half D drug plan premiums and value sharing).

Beneath the Medicare Financial savings Applications, state Medicaid packages pay for premiums and/or value sharing for Medicare beneficiaries who’ve month-to-month incomes as much as 135% FPL underneath federal tips ($1,715 for people and $2,320 for {couples} in 2024) and belongings as much as 300% of the restrict for Supplemental Safety Earnings ($9,430 for people and $14,130 for {couples} in 2024; not like SSI, asset limits for the Medicare Financial savings Applications are adjusted for inflation and enhance every year). There are 4 eligibility classes throughout the Medicare Financial savings Applications (field 1), which confer completely different advantages based mostly on completely different eligibility standards. States should cowl individuals who meet the federal eligibility necessities for the Medicare Financial savings Applications however might elect to extend earnings or asset eligibility limits past federal ranges.

In 2021, 92% of partial-benefit dual-eligible people have been primarily eligible for Medicaid by way of the Medicare Financial savings Applications (Determine 3, Appendix Desk 3). Among the many 3.4 million folks eligible for partial Medicaid advantages, greater than 9 in ten have been eligible by way of the Medicare Financial savings Applications (3.1 million folks). In all however six states, greater than 80% of partial-benefit dual-eligible people have been eligible by way of the Medicare Financial savings Applications. Among the many remaining 8%, the biggest eligibility class was by way of medically needy protection (2% of partial profit people, fewer than 0.1 million folks). Twin-eligible people might have partial Medicaid advantages by way of medically needy packages as a result of states might elect to solely cowl a subset of Medicaid advantages by way of their medically needy packages. The remaining 6% of partial-benefit dual-eligible people have been eligible by way of different partial-benefit pathways similar to these for household planning providers, people needing therapy for breast or cervical most cancers, and different eligibility pathways that will have occurred at another level within the 12 months.

Modifications in eligibility and enrollment for the Medicare Financial savings Applications

In 2024, 18 states reported having earnings and/or asset ranges above federally required ranges for the Medicare Financial savings Applications. (Determine 4, Appendix Desk 3). General, 33 states use the federal eligibility standards, and the remaining 18 states—dwelling to 1.1 million or a 3rd (33%) of partial-benefit dual-eligible people—have extra beneficiant eligibility limits on earnings, belongings or each:

3 states have both earnings or asset ranges increased than the federally required ranges (Colorado, Indiana, and Minnesota)
9 states use the federal earnings ranges however don’t have any asset take a look at (Alabama, Arizona, California, Delaware, Louisiana, Mississippi, New Mexico, Oregon, and Vermont)
6 states have earnings ranges increased than federally required and no asset take a look at (Connecticut, District of Columbia, Maine, Massachusetts, New York, and Washington).

Most of the increased earnings and asset eligibility insurance policies have been new in 2024. Of the 7 states with increased earnings ranges, 3 states reported elevating the earnings eligibility standards in 2024: Indiana elevated the earnings restrict for the Certified People program to 200% FPL, Massachusetts raised the earnings limits for the entire packages, and Washington elevated the earnings restrict for Certified Medicare Beneficiary Program. (The remaining 4 states had increased earnings limits in earlier years however didn’t enhance them in 2024.) Among the many two states with asset limits increased than federally required ranges, Colorado reported that change for the primary time in 2024, however Minnesota had increased asset limits in earlier years. Among the many 15 states with no restrict on belongings, that coverage was new to California, Maine, and Massachusetts in 2024.

A few of the 2024 eligibility modifications could also be responses to a 2023 ultimate rule on eligibility and enrollment within the Medicare Financial savings Applications. CMS expects the ultimate rule to extend enrollment within the Medicare Financial savings Applications by practically 1 million. New enrollments embrace individuals who enroll within the Medicare Financial savings Applications due to the rule, and features in months of protection amongst individuals who would have enrolled anyway however now face fewer administrative boundaries, leading to both gaining Medicaid earlier or experiencing much less churn out and in of this system. Prior KFF analysis discovered that many low-income Medicare beneficiaries will not be enrolled within the Medicare Financial savings Applications. The rule reduces boundaries to protection by enhancing alignment between the Medicare Financial savings Applications and purposes for Medicare’s Half D Low-Earnings Subsidy, requiring states to robotically enroll Medicare beneficiaries with SSI into the Medicare Financial savings Applications, and making it simpler for candidates to doc their monetary assets when making use of for Medicaid.

In 2024, 31 states reported that they already robotically enroll Medicare beneficiaries who obtain SSI into the Medicare Financial savings Applications, one of many key necessities of the brand new rule (Appendix Desk 4). Of the remaining states, 15 reported plans to take action by October 2024, whereas 4 states reported needing further time to conform. Amongst states not already in compliance, the most typical causes cited have been associated to modernizing or updating current programs to implement the change.

Strategies

Medicaid Monetary Eligibility and Enrollment Insurance policies Information: KFF’s 50-state survey and from administrative information from the Facilities for Medicare and Medicaid Companies (CMS). KFF’s Survey of Medicaid Monetary Eligibility & Enrollment Insurance policies for Seniors & Folks with Disabilities was performed in March 2024 by KFF and Watts Well being Coverage Consulting.

Enrollment Information: Information are from a KFF analytic file that merged the Facilities for Medicare & Medicaid Companies Persistent Situations Information Warehouse 2021 research-identifiable Grasp Beneficiary Abstract File (MBSF) Base and the 2021 Reworked Medicaid Statistical Info System (T-MSIS) Analytic Recordsdata (TAF) Analysis Identifiable Recordsdata (RIF) file utilizing a Persistent Situations Warehouse (CCW) beneficiary identifier crosswalk.

State inclusion standards: Estimates embrace enrollees dwelling within the 50 states and DC, excluding residents within the territories.

Twin-eligible particular person inclusion standards: Twin-eligible people have been included if (1) they have been in each the MBSF and T-MSIS recordsdata utilizing the CCW crosswalk, and (2) Twin-eligible people are assigned full-benefit standing and partial profit standing utilizing an “ever” method and a hierarchy by giving precedence to the full-benefit standing. People have been a full-benefit dual-eligible particular person in 2021 utilizing the Medicare month-to-month DUAL_STUS_CD with values of 02,04,08 or the Medicaid month-to-month code DUAL_ELGBL_CD with values of 02,04,08 or the month-to-month code RSTRCTD_BNFTS_CD_03 values of 1,A,D,4,5,7.If not a full-benefit dual-eligible and the person had  DUAL_STUS_CD with values of 01,03,05,06 or the Medicaid month-to-month code DUAL_ELGBL_CD with values of 01,03,05,06 or the month-to-month code RSTRCTD_BNFTS_CD_03 values of two,3,C,6,E,F they have been assigned partial-benefit standing.

Project to Medicaid eligibility classes. Twin-eligible people have been assigned to every eligibility class through the use of the ELGBLTY_GRP_CD_LTST in 2021.

Eligibility teams for full-benefit dual-eligible people:

Supplemental social safety earnings (SSI) with values of 11-22, 37, 38, 40, 41
Seniors and Folks with Disabilities as much as 100% FPL (SPD) with values of 46.
Medically needy with values of 53-56, 59, 60.
HCBS Growth with values of 39, 43, 51.
Particular Earnings Rule to Prolong LTSS Eligibility as much as 300% SSI (Institutional) with a price of 42.
Particular Earnings Rule to Prolong LTSS Eligibility as much as 300% SSI (HCBS) with a price of 52.
Incapacity work packages with values of 47, 48, 49.
Katie Beckett with values of 45, 50.
All different ELGBLTY_GRP_CD values have been categorized as Different/Unknown.

Eligibility teams for partial-benefit dual-eligible people:

Medicare Financial savings Program (MSP) with values of 23-26.
Medically needy with values of 53-56, 59, 60.
All different ELGBLTY_GRP_CD values have been categorized as Different/Unknown.

Different and unknown eligibility teams. Amongst all dual-eligible people, 8% had “different” or “unknown” within the eligibility group variable. These pathways included lacking values and values for the smaller eligibility teams, practically all of which correspond to eligibility for youngsters and fogeys. Medicare beneficiaries could also be eligible for Medicaid by way of these pathways, however in observe few are as a result of to qualify for Medicare folks should both be ages 65 and older or have disabilities that qualify them for Social Safety Incapacity Insurance coverage. There have been a small variety of dual-eligible people who have been recorded has having protection by way of the Inexpensive Care Act (ACA) Medicaid enlargement, however persons are not eligible for ACA protection if they’re enrolled in Medicare. The classification of dual-eligible people as having ACA protection within the knowledge could also be partially because of the steady enrollment provision, which might have carried over an eligibility standing from earlier than the particular person certified for Medicare.

One limitation to the evaluation is {that a} vital minority (10%) of full-benefit dual-eligible people have the Medicare Financial savings Applications recognized as their eligibility code within the Medicaid administrative knowledge. Most full-benefit dual-eligible people are eligible for the Medicare Financial savings Applications, however that eligibility solely qualifies them to obtain Medicaid protection of Medicare premiums and sometimes, value sharing. To obtain full Medicaid advantages, they need to even be eligible by way of one of many Medicaid eligibility pathways, however that pathway is unknown if the state recorded “Medicare Financial savings Applications” as their eligibility code within the administrative knowledge. Associated, this evaluation doesn’t embrace estimates of the whole variety of folks enrolled within the Medicare Financial savings Applications—solely the variety of dual-eligible people for whom the Medicare Financial savings Applications are the one foundation for his or her Medicaid eligibility.