Protecting the Medically Vulnerable Amid COVID-19
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COMMENTARY
Protecting the Medically Vulnerable Amid COVID-19:
Insights from the Dually Eligible Population in the
United States
Ahimsa Govender, MPH, Policy Analyst; Sarita A. Mohanty, MD, MPH, MBA,
President and CEO, The SCAN Foundation; Julie Bynum, MD, MPH, Margaret
Terpenning Professor of Internal Medicine, Department of Internal Medicine,
University of Michigan; and Vijeth Iyengar, PhD, Brain Health Lead and Technical
Advisor to the Deputy Assistant Secretary for Aging, US Department of Health and
Human Services
July 19, 2021
Introduction tends to be predominantly younger in age, female, and
comprised of an ethnically and racially diverse popula-
Dually eligible beneficiaries are individuals enrolled in
tion compared to Medicare-only beneficiaries. In 2019,
both Medicare and Medicaid. COVID-19 has exacerbat-
48.0 percent of dually eligible beneficiaries were from
ed existing vulnerabilities within this population such
minority populations, compared with 21.6 percent of
as mental health, underscoring the importance of ad-
Medicare-only beneficiaries; 59.4 percent of dually
vancing knowledge of and supporting existing efforts
eligible beneficiaries were female compared with 53.0
to meet their needs and identifying promising prac-
percent of Medicare-only beneficiaries; and 37.9 per-
tices integral to addressing current health inequities.
cent of dually eligible beneficiaries were younger than
To emphasize the increasing impact the dually eli-
65 compared with 8.1 percent of Medicare-only ben-
gible beneficiary population will have on the US health
eficiaries [1].
care landscape, this commentary serves as a primer
Dually eligible beneficiaries under age 65 qualify
for readers by:
for Medicare based on disability status and qualify
1. providing an overview of the challenges and
for Medicaid based on income level. As a result, these
needs faced by dually eligible beneficiaries;
beneficiaries often need and use other supportive
2. discussing current pathways to address care for
services, including home-based services and nursing
this population as a result of the COVID-19 pan-
home care. Dually eligible beneficiaries over 65 qualify
demic; and
for Medicare and Medicaid because of their level of
3. identifying promising strategies to address the
income and spend down in nursing homes. Dually eli-
needs of this population during and after the
gible beneficiaries use Medicare to cover primary care,
COVID-19 pandemic.
many preventive services, hospital care, and prescrip-
Who Are Dually Eligible Beneficiaries? tion drugs. They use Medicaid as a secondary payer
to cover services not covered by Medicare, including
The dually eligible population has grown from 8.6 mil-
long-term services and supports, certain behavioral
lion in 2006 to 12.3 million beneficiaries in 2019, with
health services, and for those who qualify, Medicare
an average annual growth rate of 2.8 percent [1]. In
premiums and cost-sharing. Some dually eligible ben-
2013, dually eligible beneficiaries accounted for $312.4
eficiaries are encumbered by multiple chronic condi-
billion in Medicare and Medicaid combined spending
tions, long-term care needs, and cognitive disabilities
[2]. As a population with complex needs, dually eligible
including mental illnesses [4]. Some in this population
beneficiaries account for a significant portion of total
also have adverse social determinants of health from
Medicare and Medicaid spending primarily due to their
social risk factors including lack of transportation, food
heavy reliance on long-term care services and inpa-
insecurity, and housing insecurity [5].
tient hospitalizations [3]. This beneficiary population
Perspectives | Expert Voices in Health & Health CareCOMMENTARY
Dually Eligible Beneficiaries Face Incredible COVID-19 have restricted visitation and social engage-
Challenges during COVID-19 ment to curtail viral transmission, and (2) beneficiaries
who receive home- and community-based services
The health and economic challenges experienced by
(HCBS)—a Medicaid benefit that provides an opportu-
dually eligible beneficiaries have persisted and esca-
nity for dually eligible beneficiaries to receive care in
lated amidst the COVID-19 pandemic. Accumulating
their home or community settings as opposed to insti-
evidence suggests that this population bears a higher
tutional care—have limited access to care and support
likelihood of being exposed to COVID-19 as a result of
during the pandemic because of concerns about allow-
medical risk factors, racial and ethnic inequities, and
ing personal care attendants into their homes. Dually
adverse social determinants of health.
eligible beneficiaries may face additional issues includ-
Medical Risk Factors ing limited transportation options to doctors’ appoint-
Dually eligible beneficiaries are burdened with chronic ments (which could delay their care and treatment and
conditions [4] (e.g., Alzheimer’s and related dementias, exacerbate potential health complications), increased
asthma, chronic obstructive pulmonary disease, and food insecurity for beneficiaries who relied on receiv-
diabetes), which are also key risk factors for contract- ing food from community settings, and less telehealth
ing COVID-19 [6]. Preliminary data from the Centers access, particularly for older individuals [10].
for Medicare & Medicaid Services (CMS) indicate dually The glaring gap of essential services during the pan-
eligible beneficiaries are almost three times as likely to demic may increase dually eligible beneficiaries’ rates
get infected and be hospitalized because of COVID-19 of illness, hospitalizations, and potential exposure to
[7]. COVID-19. Given the complex needs of the dually eli-
gible population, a substantial proportion of whom re-
Racial and Ethnic Inequities side in nursing homes, and the loss of integral services
COVID-19 has emphasized stark inequities and health from the pandemic, it is perhaps unsurprising that they
disparities when addressing the needs of this popu- are at a higher risk of being impacted by COVID-19.
lation. For example, American Indian/Alaska Native, Fortunately, current strategies and promising practices
Latinx, and Black dually eligible beneficiaries are more have been used to meet the needs and challenges ex-
likely to be hospitalized for COVID-19 than White du- perienced by this population amidst the pandemic and
ally eligible beneficiaries. In addition, American Indian/ beyond.
Alaska Native and Latinx dually eligible beneficiaries
are more likely to be infected with SARS-CoV-2 com- Current Strategies to Address Dually Eligible
pared with White dually eligible beneficiaries [7]. Beneficiary Needs amid COVID-19
To combat the pandemic and ensure access to high-
Adverse Social Determinants of Health
quality health care and supports for dually eligible
Coupled with risk factors, adverse social determinants
individuals, organizations have incorporated more
of health have posed challenges for dually eligible
flexibility to address the health and social needs of
beneficiaries during the pandemic. A recent study ex-
beneficiaries. For example, Program of All-Inclusive
plored ways in which 14 integrated, coordinated care
Care for the Elderly (PACE) organizations provide ser-
plans that target dually eligible beneficiaries such as
vices for over 50,000 older adults [11] in 31 states and
Dual Eligible Special Needs Plans (D-SNPs)—which,
primarily serve dually eligible beneficiaries who would
as of June 2021, enroll 3.5 million dually eligible ben-
be eligible for nursing home care (90 percent of PACE
eficiaries [8]—and Medicare-Medicaid Plans (MMPs)
enrollees are dually eligible) among other populations
addressed social determinants of health during the
nationwide. PACE organizations also provide necessary
pandemic. During the early stages of the pandemic,
medical and social services including adult day services
plans reported that beneficiaries had difficulties ad-
and other HCBS, nursing home care, meals, prescrip-
dressing food needs and social isolation, followed by
tion drugs, and various counseling services and ther-
access to housing, basic home supplies and personal
apy, and they cover enrollees’ emergency services and
protective equipment [9]. Social isolation in particular
hospital care. PACE organizations receive capitated
may be a potential risk among older beneficiaries liv-
payments from Medicare, which incentivize decreased
ing in residential facilities (e.g., nursing facilities) and
inpatient hospital and skilled nursing facility costs. Evi-
community settings, for reasons including: (1) safety
dence reveals that PACE organizations have lower hos-
restrictions established in nursing facilities to combat
Page 2 Published July 19, 2021Protecting the Medically Vulnerable amid COVID-19: Insights from the Dually Eligible Population in the United States
pital utilization and shorter hospital stays. In response such as nursing facilities to HCBS. While some states
to COVID-19, some PACE organizations were encour- already use MFP resources to address social needs for
aged to rapidly pivot to providing increased telehealth dually eligible beneficiaries as they transition back to
services, delivering meal services during the day, and the community, encouraging states to transition more
supporting medication adherence [12]. dually eligible beneficiaries to community-based set-
Complementing these health care delivery efforts, tings under this program could mitigate their exposure
through their care coordinators, D-SNPs and MMPs to COVID-19, especially given the adverse effects from
communicated directly with their beneficiaries through residing in nursing facilities. In addition, dually eligible
outreach to address unmet health and social needs. beneficiaries’ higher risk for significant mental health
Specifically, they addressed beneficiaries’ food inse- needs, which has increased during the pandemic,
curity challenges through expanding emergency meal could be addressed by states continuing to implement
programs and coordinating food delivery from local existing models such as the Financial Alignment Initia-
banks. These plans also delivered basic home supplies tive, which integrates primary and acute care, behav-
to beneficiaries, communicated with beneficiaries who ioral health, and long-term services and supports for
were struggling with social isolation and loneliness, and dually eligible beneficiaries and existing state-based
connected beneficiaries with appropriate resources for care-coordination health plans (e.g., Cal MediConnect)
their financial needs [9]. In addition, coordinated care that can help to address mental health challenges for
plans like D-SNPs and MMPs and PACE organizations this population. A look at data systems suggests that
include flexible benefit packages and are developing further linkages between existing federal data sur-
ways to vaccinate this population, including monitoring veys and data collection systems (e.g., the Centers for
vaccination uptake, implementing reward and incen- Disease Control and Prevention’s National Center for
tive programs to increase vaccination, and using Med- Health Statistics’ data collection systems) with CMS
icaid’s nonemergency medical transportation benefit data may support future efforts to better identify dual-
for qualified dually eligible enrollees to access vaccines ly eligible beneficiaries with unmet needs, understand
[13]. their health and social needs, and ultimately improve
Facilitating communication between community re- their quality of care.
sources and beneficiaries in addition to using flexibili- Enhanced federal Medicaid funding to states would
ties within D-SNPs, MMPs, and PACE organizations will emphasize addressing social determinants of health.
support beneficiaries to gain access to necessary social For example, this funding may support coverage of ad-
services during the pandemic. ditional health and social services including transpor-
tation options, protective personal equipment, meal
Beyond COVID-19: Improving the Health Out- delivery or other ways to address food insecurity, and
look for Dually Eligible Beneficiaries access to vaccinations that states do not otherwise
The COVID-19 pandemic has accelerated the adoption cover under state plan amendments or Section 1115
and consideration of promising practices to address waiver demonstrations.
the health and social needs of dually eligible beneficia- Additionally, the Creating High-Quality Results and
ries. These practices focus on three key aspects: Outcomes Necessary to Improve Chronic Care Act iden-
1. leveraging existing initiatives and data systems tified a pathway of using Special Supplemental Benefits
to improve quality of care; for the Chronically Ill (SSBCI) for Medicare beneficiaries,
2. increasing emphasis on social determinants of including dually eligible beneficiaries. SSCBI covers
health; and nonmedical needs that are not covered by Medicaid
3. increasing access to health and social services such as nonmedical transportation, food, and indoor
through telemedicine. air quality equipment services that Medicare Advan-
tage plans can provide. Although few plans provided
Existing initiatives and federally managed data sys- these benefits in 2020 partly due to operational chal-
tems play a critical role in improving quality of care lenges, an increased number of plans provided more
for beneficiaries. The Money Follows the Person (MFP) health-related benefits. This year however, plans may
Rebalancing Demonstration Program is a Medicaid consider, as evidence suggests, offering more nonmed-
program that provides enhanced federal funding for ical benefits that address social determinants of health
states to transition Medicaid beneficiaries, including [14].
dually eligible beneficiaries, from institutional settings
NAM.edu/Perspectives Page 3COMMENTARY
Lastly, while, telemedicine has become increasingly 3. Bynum, J. P. W., A. Austin, D. Carmichael, and E.
adopted as a tool for health care service and delivery Meara. 2017. High-cost dual eligibles’ service use
during the pandemic, dually eligible beneficiaries are demonstrates the need for supportive and pal-
less likely to have internet and smart phone access. To liative models of care. Health Affairs 36(7): 1309-
improve upon existing PACE organization efforts, tele- 1317. https://doi.org/10.1377/hlthaff.2017.0157.
health services could address health disparities in the 4. CMS Medicare-Medicaid Coordination Office.
dually eligible beneficiary population by encouraging 2020. People Dually Eligible for Medicare and Medic-
public-private partnerships between the federal gov- aid (Fact Sheet). Available at: https://www.cms.gov/
ernment and the private entities who have experience Medicare-Medicaid-Coordination/Medicare-and-
working with beneficiaries residing in traditionally un- Medicaid-Coordination/Medicare-Medicaid-Coor-
derserved communities. For example, private entities dination-Office/Downloads/MMCO_Factsheet.pdf
may consider providing services in underserved areas (accessed February 16, 2021).
such as user-friendly and potentially reusable techno- 5. Sorbero, M. E., A. M. Kranz, K. E. Bouskill, R. Ross,
logical devices (e.g., mobile phones or tablets) that en- A. I. Palimaru, and A. Meyer. 2018. Addressing
able beneficiaries to navigate telehealth appointments social determinants of health needs of dually en-
and any necessary follow-ups. In addition, current COV- rolled beneficiaries in Medicare Advantage plans:
ID-19 Medicare and Medicaid telehealth flexibilities fo- Findings from interviews and case studies. RAND
cused on telehealth reimbursement can continue to be Corporation. Available at: https://www.rand.org/
used after the public health emergency ends. Ultimate- pubs/research_reports/RR2634.html (accessed
ly, offering these specific supports will improve health February 16, 2021).
equity and prevent potential adverse health outcomes. 6. Centers for Disease Control and Prevention (CDC)).
2020. Science Brief: Evidence used to update the list
Conclusions of underlying medical conditions that increase a per-
The dually eligible beneficiary population is a burgeon- son’s risk of severe illness from COVID-19. Available
ing patient population, posing considerable economic at: https://www.cdc.gov/coronavirus/2019-ncov/
and health impacts to the US health care system. Given need-extra-precautions/evidence-table.html (ac-
the sheer heterogeneity of beneficiaries and accompa- cessed February 16, 2021).
nying multifactorial nature of their medical and social 7. Centers for Medicare & Medicaid Services (CMS).
needs, multisectoral solutions are required to meet 2020. Preliminary Medicare COVID-19 Data Snap-
the needs of this population. This commentary pro- shot. Available at: https://www.cms.gov/files/doc-
vides promising strategies such as telehealth flexibili- ument/medicare-covid-19-data-snapshot-fact-
ties, HCBS expansion for states, and SSBCI benefits to sheet.pdf (accessed April 3, 2021).
improve care for the dually eligible population. It also 8. Centers for Medicare & Medicaid Services (CMS).
serves as a mechanism for stakeholders from the pri- 2021. SNP Comprehensive Report 2021-06. Available
vate, philanthropic, and civil society to collaborate and at: https://www.cms.gov/research-statistics-data-
identify novel ways or build on existing initiatives to and-systemsstatistics-trends-and-reportsmcrad-
provide appropriate care and targeted supports for vpartdenroldataspecial-needs/snp-comprehen-
these beneficiaries amidst COVID-19 and beyond. sive-report-2021-06 (accessed June 15, 2021).
9. Archibald, N. 2021. Addressing Social Needs Amid
References the COVID-19 Pandemic: A Survey of Dual Eligible
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Page 4 Published July 19, 2021Protecting the Medically Vulnerable amid COVID-19: Insights from the Dually Eligible Population in the United States
covid-19s-effect-on-dually-eligible-populations- Professor of Internal Medicine, Department of Internal
using-home-and-community-based-services/ (ac- Medicine, University of Michigan. Vijeth Iyengar, PhD,
cessed February 16, 2021). is brain health lead and technical advisor to the Deputy
11. Centers for Medicare & Medicaid Services (CMS). Assistant Secretary for Aging, Administration for Com-
2021. Contract Summary 2021-06. Available at: munity Living, US Department of Health and Human
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and-systemsstatistics-trends-and-reportsm-
cradvpartdenroldatamonthly/contract-summa- Acknowledgments
ry-2021-06 (accessed June 15, 2021) The authors would like to thank Tracy Lustig, DPM,
12. Montgomery, A., A. Slocum, F. F. O’Reilly, R. Sch- MPH, senior program officer of the Health and Medi-
reiber, J. Lynn, and M. Phife. 2020. Rapid PACE Re- cine Division at the National Academies of Sciences;
sponses in a COVID-19 Era: How PACE Providers Have Rukshana Gupta, BAS, senior program assistant of the
Innovated and Adapted to Keep Enrollees Safe in Health and Medicine Division at the National Academies
Their Communities. Altarum Institute. Available at: of Sciences; Sara Vitolo, MSPH, deputy director at the
https://altarum.org/sites/default/files/uploaded- Medicare-Medicaid Coordination Office within the Cen-
publication-files/Altarum_Program-to-Improve- ters for Medicare & Medicaid Services; Molly Knowles,
Eldercare_Rapid-PACE-Responses_report_final.pdf MPP, senior program officer at the Center for Health
(accessed February 16, 2021). Care Strategies; and Julie Pavlin, MD, PhD, MPH, direc-
13. Centers for Medicare & Medicaid Services (CMS). tor of Board on Global Health at the National Academies
2021. Opportunities to maximize COVID-19 vaccina- of Sciences, Engineering, and Medicine, for providing
tions among dually eligible individuals. Available at: feedback and guidance throughout the development of
https://www.cms.gov/files/document/covid-dual- this commentary.
eligible-vaccine-hpms-memo.pdf (accessed March
17, 2021) Conflict-of-Interest Disclosures
14. Kornfield, T., M. Kazan, M. Frieder, R. Duddy- Sarita A. Mohanty, MD, MPH, MBA receives a stipend
Tenbrunsel, S. Donthi, and A. Fix. 2021. Medicare for serving on the board for COPE Health Solutions and
Advantage Plans Offering Expanded Supplemen- is Quality Policy Fellow for the National Quality Forum
tal Benefits: A Look at Availability and Enrollment. (NQF). Julie Bynum, MD, MPH receives grant funding
The Commonwealth Fund. Available at: https:// from the National Institutes of Health, is a consultant to
www.commonwealthfund.org/publications/issue- the Alzheimer’s Association, is a member of America’s
briefs/2021/feb/medicare-advantage-plans-sup- Health Rankings Advisory Council, and is on the Regen-
plemental-benefits (accessed February 16, 2021). strief Institute’s External Advisory Board.
DOI Correspondence
https://doi.org/10.31478/202107c Questions or comments should be directed to Ahimsa
Govender at govendas108@gmail.com.
Suggested Citation
Govender, A., S. A. Mohanty, J. Bynum, and V. Iyengar. Disclaimer
2021. Protecting the Medically Vulnerable amid CO- The views expressed in this paper are those of the au-
VID-19: Insights from the Dually Eligible Population in thors and do not necessarily represent the views of the
the United States. NAM Perspectives. Commentary, Na- US Government and US Department of Health and Hu-
tional Academy of Medicine, Washington, DC. https:// man Services, the National Academy of Medicine (NAM),
doi.org/10.31478/202107c. or the National Academies of Sciences, Engineering, and
Medicine (the National Academies). The paper is intend-
Author Information ed to help inform and stimulate discussion. It is not a
Ahimsa Govender, MPH, is a policy analyst. Sarita A. report of the NAM or the National Academies. Copyright
Mohanty, MD, MPH, MBA is president and CEO, The by the National Academy of Sciences. All rights reserved.
SCAN Foundation and adjunct associate professor, Kai-
ser Permanente Bernard J. Tyson School of Medicine.
Julie Bynum, MD MPH, is the Margaret Terpenning
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