Carper, Cassidy, Cornyn, Warner, Scott, Menendez Comprehensive Legislation Improve Care for Patients Jointly Enrolled in Medicare and Medicaid

U.S. Senators Tom Carper (D-Del.), Bill Cassidy, M.D. (R-La.), John Cornyn (R-Texas), Mark Warner (D-Va.), Tim Scott (R-S.C.), and Bob Menendez (D-N.J.), members of the Senate Duals Working Group, introduced the Delivering Unified Access to Lifesaving Services (DUALS) Act of 2024 to improve coverage for individuals jointly enrolled in Medicare and Medicaid, also known as dual eligibles.

“Beneficiaries who are dually eligible for Medicare and Medicaid are often the sickest and most vulnerable patients in our country, and, particularly for these patients, we must reduce the unnecessarily complex nature of health care in America,” said Senator Carper. “This bipartisan bill directly works to simplify complexities for the millions of dual eligible Americans in need, while simultaneously reducing bureaucratic headaches for the government, health care providers, and patients alike. We’ve worked hard over the last three years to draft this legislation, and I’m proud to introduce the product of our years of work today.”

“Patients dually eligible for Medicare and Medicaid have much worse outcomes than other groups even though there is a lot more money spent on their care,” said Dr. Cassidy. “Making Medicare and Medicaid better work together makes patients healthier and saves money for taxpayers.”

“Medicare and Medicaid oftentimes don’t coordinate care for individuals enrolled in both programs, which can lead to poor outcomes for patients and inefficient spending for our health care system,” said Senator Cornyn. “By requiring states to develop an integrated health plan for these Americans, this legislation would help streamline the system, improve beneficiary experience, and ensure taxpayer dollars are spent responsibly.”

“This bill is the result of a year of work and input from stakeholders across the country,” said Senator Warner. “It responds directly to what we heard and what we’ve known for awhile, which is that the status quo isn’t working. This bill will help make sure that duals have access to improved, integrated care, and that states receive additional resources so that they can more fully support this vulnerable population.”

“Many states lack fully integrated care between Medicare and Medicaid, leaving dually eligible individuals with fragmented care and the headaches of confusing bureaucracy. We can, and must, do better for this vulnerable population,” said Senator Scott. “Our bill will help ensure these programs work together so that patients across the nation can access the high quality care they deserve.”

The DUALS Act of 2024: 

• Requires each state, with support from the Centers for Medicare & Medicaid Services (CMS), to select, develop and implement a comprehensive, integrated health plan for dual-eligible beneficiaries.  States can create a new system or build off of existing coverage options.
• Improves beneficiary experience by requiring plans to develop and update care coordination plans, requiring the establishment of ombudsman offices, and establishing a care coordinator for each beneficiary.
• Reduces beneficiary confusion by reducing “look-alike” plans which target dual eligible beneficiaries for enrollment but don’t provide any coordination, creates a single appeals process instead of the current Medicare and Medicaid appeals process, and reduces third-party marketing organization incentives to target beneficiaries.
• Expands Program of All-Inclusive Care for the Elderly (PACE) coverage nationwide by requiring every state to allow PACE programs to be established, allows enrollment in a PACE program at any time in the month, and expands PACE coverage to individuals under the age of 55.

The DUALS Act of 2024 is supported by Centerlight Healthcare, Santa Clara Family Health Plan, Association for Community Affiliated Plans (ACAP), PointClickCare, Welbe Health, American Kidney Fund, National Multiple Sclerosis Society, Alliance of Community Health Plans, LeadingAge, Bipartisan Policy Center, National Health Council, ChristianaCare, DaVita, and National Pace Association.

Click here for the one-pager. 

Click here for a section-by-section.

Background

The Duals Working Group convened in November 2022 as they sought feedback from the health care and patient communities to develop legislation that would improve coverage for dual eligibles. The working group requested specific information regarding shortfalls in the current system of care for dual eligibles, how to improve patient health outcomes, and the role of federal or state governments in dual eligibles’ care. In May 2023, the Working Group released discussion draft legislation for feedback.

In May 2023, the Working Group released discussion draft legislation for feedback.

Cassidy also co-authored a Viewpoint in the Journal of the American Medical Association on patients jointly enrolled in Medicare and Medicaid. The Viewpoint asserts that poor payment coordination between Medicare and Medicaid drives uncoordinated care and worse outcomes for a majority of dual eligible patients.

Approximately 12.2 million low-income or disabled people in the United States are jointly enrolled in Medicare and Medicaid. Dual eligibles are a diverse group with a complex, unique set of needs. This population includes individuals with multiple chronic conditions, physical disabilities, mental illness, and cognitive impairments such as dementia and developmental disabilities, and others who are relatively healthy.

While representing a small proportion of Medicare and Medicaid beneficiaries, dual eligibles account for a disproportionate share of overall spending. In the Medicare program, 19% of enrollees are dually eligible but account for 34% of spending. Similarly, 14% of Medicaid enrollees are dually eligible but constitute 30% of overall spending. In 2019, combined Medicare and Medicaid spending on dual eligibles rose to a total of $440.2 billion.

The COVID-19 pandemic has further exposed the need for reforms to systems of care for dual eligibles. According to federal data, across every demographic group dual eligibles were more likely to contract COVID-19. More concerning, dual eligibles were more than three times as likely to be hospitalized from COVID-19 compared to Medicare only individuals.

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