Opportunities for Integration in the Dual Medicare-Medicaid Population: North Carolina Landscape Analysis

Background: NC Medicaid is amid a transformation to value-based care models. The transformation requires the consideration of models that may best serve the 1 in 5 NC Medicaid beneficiaries who are dually enrolled in Medicare. The lack of integration of Medicare and Medicaid administration, financing, and care may contribute to suboptimal health outcomes and care experiences. Integrating Medicare and Medicaid to improve care for dually enrolled individuals requires knowledge of the demographic, eligibility, and enrollment trends, as well as the medical needs of these individuals throughout North Carolina.

Methods: We performed a cross-sectional analysis of 2019 NC Medicaid administrative enrollment data and 2015-2020 Medicare and Medicaid public use files.

Results: Nearly half of North Carolina's full-benefit dual-eligible (FBDE) population was eligible for Medicare due to disability. About one-third of the FBDE population lost full Medicaid benefits at some point during 2019; of these, 65% were under age 65. Most FBDE beneficiaries were enrolled in Medicaid fee-for-service, with 3.5% enrolled in Community Alternatives Program (CAP) waivers, 2% in Medicaid waivers for beneficiaries with behavioral health or intellectual and developmental disabilities (BH/IDD) or traumatic brain injury (TBI), and 1% in the Program of All-Inclusive Care for the Elderly (PACE). Enrollment in Medicare Duals Special Needs Plans (D-SNPs) increased from 7.3% of the FBDE population in 2015 to 32.5% in 2021.

Limitations: This descriptive, cross-sectional evaluation of North Carolina duals may not be generalizable to other time periods and contexts.

Conclusion: Medicare-Medicaid integration presents an opportunity to improve the value of care for dual-eligible beneficiaries and aligns with the goals of NC Medicaid transformation. Integration strategies that leverage the current infrastructure may minimize disruption of services for beneficiaries and mitigate the impacts of unstable enrollment, particularly among working-age adults and disabled beneficiaries. The diversity within the dual-eligible populations requires a strategy designed to improve health equity across race, disability, eligibility, geography, and health care needs.