When Medicare-Medicaid enrollees lose their Medicaid coverage: Who loses it, for how long, and what are the consequences?

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1 When Medicare-Medicaid enrollees lose their Medicaid coverage: Who loses it, for how long, and what are the consequences? Gerald Riley Lirong Zhao Negussie Tilahun

2 Medicare-Medicaid enrollees Vulnerable population with complex health care needs Medicaid coverage sometimes stops Changes in income/assets Return to work (disabled under age 65) Spend-down Non-renewal of Medicaid enrollment Loss of Medicaid may have adverse consequences Disrupt initiatives to integrate Medicare and Medicaid Affect access to care

3 Research questions How common is loss of Medicaid coverage among Medicare- Medicaid enrollees? What is duration of losses and frequency of reinstatement? Who loses Medicaid coverage? Does rate of loss vary among States? Do Medicare-Medicaid enrollees who lose Medicaid coverage have other sources of supplemental insurance? Does loss of Medicare Part D or Part B coverage follow loss of Medicaid?

4 Data and study design Annual Medicare master beneficiary summary files Monthly data on Parts A, B, D, low income subsidy, managed care enrollment, Medicaid eligibility reported by states, demographics Identified 5% sample of beneficiaries with Medicare and Medicaid eligibility as of January, 2009 (N=385,278) Included those with both full and partial Medicaid benefits Linked to Medicaid MAX person summary file 2008 Linked to CMS-HCC risk scores Followed cohort through December, 2011

5 Loss of Medicaid coverage among Medicare-Medicaid enrollees All enrollees Full Medicaid benefits Partial Medicaid benefits N 385, ,184 91,094 Lost Medicaid 14% 12% 23% regained 59% 60% 58% lost > once 14% 15% 13% Months lost % 35% 33% % 30% 30% % 35% 38%

6 Beneficiary characteristics associated with loss of Medicaid coverage Characteristic N Percent losing Medicaid Adjusted odds ratio Total 385, % Age < ,689 19% ,355 14% ,982 10% ,252 7% Ref. Changed state of residence Yes 16,748 36% 3.62 No 368,530 13% Ref.

7 Beneficiary characteristics associated with loss of Medicaid coverage (cont.) Characteristic Medicaid payments/month in 2008 N Percent losing Medicaid Adjusted odds ratio $0 $ ,350 18% Ref. $301 $1,000 19,624 12% 0.77 $1, ,165 6% 0.50 Enrolled in prepaid plan 140,204 13% 0.92 CMS HCC risk score in 2009 < ,320 16% Ref ,155 14% ,803 12% 0.86

8 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Percent losing Medicaid coverage with 95% confidence intervals, by state LA ME DE OR NC NJ TX ND MN SD CT IA NY PA CA FL IL MA MS AL OK WY RI WI SC AZ NE VT AR HI NM AK MD WA NH CO KY MI GA WV MT OH IN VA MO TN UT NV ID KS DC

9 Proportion with Part B coverage, Part D coverage, and Part D low income subsidy following loss of Medicaid Months following loss of Medicaid Part B Part D LIS

10 Beneficiary characteristics associated with loss of Part D following loss of Medicaid for more than 6 months Characteristic N Percent losing Part D Adjusted odds ratio Total 24,743 12% Age < 65 12,975 12% ,715 11% ,663 10% ,390 9% Ref. Part D costs before losing Medicaid $0 $100 11,019 15% Ref. $101 $300 6,332 9% 0.61 $ ,809 8% 0.51

11 Identifying other sources of supplemental insurance Medicare Current Beneficiary Survey Cost & Use files Respondents report all private and public sources of supplemental health insurance We identified respondents losing Medicaid coverage during survey participation (N=933) Computed percentage reporting any supplemental health insurance during period without Medicaid coverage Counted general insurance only (not drug-only, dental, LTC) Included respondents reporting VA as a health care payer that year

12 Prevalence of Medicare supplemental insurance or VA health care following loss of Medicaid, All Age < 65 Age 65 + Number losing Medicaid Percent with supplemental insurance or VA benefits following loss of Medicaid All the time without Medicaid 35% 27% 40% Some of the time w/o Medicaid 10% 10% 11% None of the time w/o Medicaid 55% 64% 50% Percent of non Medicaid months with supplemental insurance or VA health care 45% 32% 53% Source: Medicare Current Beneficiary Survey

13 Discussion Loss of Medicaid coverage may interfere with initiatives to integrate Medicare and Medicaid services Disrupt treatment regimens for chronic conditions Prompt beneficiary disenrollment Gaps in health records, utilization data Increase administrative costs New models of integrated care should prepare for gaps in Medicaid coverage Access to care could be affected Vulnerable groups tended to be less at risk for loss of Medicaid, Medicare Part D and B

14 Limitations Unable to determine why Medicare-Medicaid enrollees lost Medicaid coverage Could not directly measure beneficiary impacts We don t know the source of state variation in loss of Medicaid coverage Could be differences in state renewal requirements and procedures Findings subject to accuracy of administrative records

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