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Data Analysis Brief:
Comparing Managed Care Enrollment Trends among Dually Eligible Individuals
to Medicare-only Beneficiaries, 2012 through 2021
Prepared by the Centers for Medicare & Medicaid Services (CMS) Medicare-Medicaid Coordination Office
October 2022
Ten-year Managed Care Enrollment Trends: 2012-2021
This Data Analysis Brief examines Medicare managed care enrollment trends of people who are dually
eligible for Medicare and Medicaid (also known as dually eligible individuals) over ten calendar years.
We also include the Medicare-only population for comparison purposes.
SUMMARY OF KEY FINDINGS
− There have been increasing proportions of individuals enrolled in Medicare managed care
across all enrollment groups over the past decade. For all dually eligible individuals,
Medicare managed care penetration grew from 22 percent in 2012 to 51 percent by 2021.
− Among dually eligible individuals, the proportion of individuals enrolled in Medicare
managed care continued to vary by level of Medicaid benefits: In 2021, 64 percent of
partial-benefit dually eligible individuals were enrolled in Medicare managed care,
compared to 46 percent of full-benefit dually eligible individuals.
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− Since 2015, a higher proportion of dually eligible individuals have been enrolled in Medicare
managed care than Medicare-only beneficiaries. In 2021, 51 percent of all dually eligible
individuals were enrolled in Medicare managed care, compared to 40 percent of the
Medicare-only population.
BACKGROUND
During the past 25 years, the Medicare coverage choices available to dually eligible individuals have
increased significantly, especially with the introduction of the Medicare Part C/Medicare Advantage
(MA) program. Under the Balanced Budget Act of 1997 (BBA; P.L. 105-33), health plan options were
expanded to allow private commercial insurers to offer an alternative to traditional fee-for-service (FFS)
Medicare in the form of specific types of health care plans. Today, these expanded options are
collectively known as the “MA program” and include health maintenance organizations (HMOs),
provider sponsored organizations (PSOs), preferred provider organizations (PPOs), and private FFS
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Full-benefit dually eligible individuals are Medicare beneficiaries who qualify for the full package of Medicaid
benefits. They often separately qualify for assistance with Medicare premiums and cost sharing through the
Medicare Savings Programs (MSPs). Partial-benefit dually eligible individuals are enrolled only in Medicare and an
MSP (see www.cms.gov/Medicare-Me
dicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-
Medicaid-Coordination-Office/Downloads/MMCO_Factsheet.pdf).
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(PFFS) plans.
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The BBA also established the Program of All-inclusive Care for the Elderly (PACE) as a
permanent Medicare coverage option (section 1894 of the Social Security Act) and allowed states the
option to pay for PACE under Medicaid (section 1934 of the Social Security Act).
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA; P.L. 108-173)
further expanded the health plan options available through the MA program by authorizing Special
Needs Plans (SNPs) to better coordinate benefits for beneficiary populations with special needs (i.e.,
dually eligible individuals, enrollees who reside in institutions, or beneficiaries with certain chronic
conditions). SNPs became a permanent part of the Medicare program through the Bipartisan Budget Act
of 2018 (P.L. 115-123).
More recently, through the Financial Alignment Initiative,
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ten states have tested a capitated integrated
delivery-payment model to improve coordination of care and align financial incentives for dually eligible
individuals.
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In this model, available only to full-benefit dually eligible individuals, participating health
plans known as Medicare-Medicaid Plans (MMPs) provide coverage for both Medicare and Medicaid
benefits.
In this brief, we refer to enrollment in MA plans, MMPs, and PACE programs as “Medicare managed
care.”
DETAILED FINDINGS
• Medicare managed care penetration has increased over time, with a greater rate of increase
for dually eligible individuals than for Medicare-only beneficiaries. Among dually eligible
individuals, the proportion enrolled in Medicare managed care increased from 22 percent in
2012 to 51 percent by 2021. For comparison, the proportion of Medicare-only beneficiaries
enrolled in managed care over the same time span increased from 27 percent to 40 percent. The
overall proportion of all dually eligible individuals enrolled in Medicare managed care surpassed
that of Medicare-only beneficiaries for the first time beginning in 2015 and has since been
continuing this upward trend.
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HMOs and PPOs are managed care plans that have provider networks and can vary plan offerings, premiums, and
benefits by county. PSOs are managed care plans operated by a group of doctors and hospitals that then form the
provider network. PFFS plans are private plans that pay providers on an FFS basis, as determined by the plan
itself.
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The Financial Alignment Initiative is being tested under the authority of CMS’ Center for Medicare and Medicaid
Innovation. For additional information about the Medicare-Medicaid FAI, see the Medicare-Medicaid
Coordination Office (MMCO) website: www.cms.gov/Medicare-Me
dicaid-Coordination/Medicare-and-Medicaid-
Coordination/Medicare-Medicaid-Coordination-
Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.
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Under the capitated model, the state, CMS, and a health plan enter a three-way contract to provide integrated
services, with the plan receiving a prospective blended payment. States currently testing the capitated model
include California, Illinois, Massachusetts, Michigan, New York, Ohio, Rhode Island, South Carolina, and Texas.
Virginia ended its capitated model demonstration in 2017, and New York transitioned one of its two
demonstrations in 2019 from the capitated model to a Medicare Advantage-based initiative. Three other states
(Colorado, Minnesota, and Washington) are testing or have tested a non-capitated model.
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Figure 1. Proportion of Full-benefit, Partial-benefit, Total Dually Eligible Beneficiaries, and
Medicare-only Beneficiaries Enrolled in Medicare Managed Care (including PACE and MMPs),
2012-2021
Appendix A presents the detailed findings.
• Managed care options for full-benefit dually eligible individuals expanded in 2014 with the
launch of MMPs.
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As of 2021, about 4 percent of full benefit dually-eligible individuals were
enrolled in MMPs, or more than 400,000 total. Overall, managed care enrollment among full-
benefit dually eligible individuals more than doubled since 2014, from 1.9 million to 4.2 million.
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MMPs began phased-in enrollment in late 2013.
0%
10%
20%
30%
40%
50%
60%
70%
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Medicare Only All Dual Full Benefit Partial Benefit
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Figure 2. Proportion of Full-Benefit Dually Eligible Individuals in Medicare-Medicaid Plans
and Other Managed Care
Appendix B presents the detailed findings.
• Nevertheless, partial-benefit dually eligible individuals have consistently had the highest
Medicare managed care enrollment rates. Medicare managed care enrollment among partial-
benefit dually eligible individuals grew from 33 percent in 2012 to 64 percent in 2021. In
contrast, among full-benefit dually eligible individuals, managed care enrollment increased from
18 percent to 46 percent over the same period.
D
ATA SOURCES AND METHODOLOGY
This analysis employed Common Medicare Environment (CME) data from the CMS Chronic Conditions
Data Warehouse (CCW). All Medicare beneficiaries, including those with Medicare Part A or Part B only,
were included in the denominator of total Medicare beneficiaries in this analysis.
This analysis used state-reported “State MMA File” data to identify dually eligible individuals. As
required by the MMA, states submit these files to CMS on an at-least monthly basis to report which of
their Medicaid beneficiaries are also eligible to receive Medicare along with their dual eligibility type.
However, federal regulations at 42 CFR 423.910 now require states, effective April 1, 2022, to submit
files daily. The State MMA File is considered the most current, accurate, and consistent source of
information on beneficiaries’ dual eligibility status for any given month. For more information on
defining dually eligible individuals in CMS administrative data sources, refer to the following resource:
www.cms.gov/Medicare-Me
dicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-
Medicaid-Coordination-Office/Downloads/MMCO_DualEligibleDefinition.pdf.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
All other managed care MMP
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This analysis included individuals with any Medicare enrollment in the year. Individuals were assigned to
one of three enrollment groups in the following hierarchical order: full-benefit dually eligible (at any
time during the year), partial-benefit dually eligible, and Medicare-only. Individuals’ most recent
enrollment of the following plan types was recorded: traditional Medicare FFS, PACE, MMP, and “other”
Medicare managed care plans.
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Graphs in Appendix A and corresponding data tables in Appendix B
indicate Medicare managed care enrollment from 2012 through 2021 for dually eligible individuals
versus Medicare-only beneficiaries and for full-benefit versus partial-benefit dually eligible individuals.
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This analysis does not include individuals in employer-sponsored plans.
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Appendix A: Managed Care Penetration by Dual Eligibility Status
Table 1. Proportion of Medicare-only Beneficiaries, All Dually Eligible Beneficiaries, Full-benefit Dually
Eligible Individuals, and Partial-benefit Dually Eligible Individuals Enrolled in Medicare Managed Care
in Each Year
Year
Medicare-
Only
All Dually Eligible Individuals
(Full- and Partial-benefit)
Full-benefit Dually
Eligible Individuals
Partial-benefit Dually
Eligible Individuals
2012
27%
22%
18%
2013
28%
24%
20%
2014
30%
28%
24%
2015
31%
31%
28%
2016
31%
33%
29%
2017
32%
35%
32%
2018
34%
37%
33%
2019
35%
41%
36%
2020
37%
45%
40%
2021
40%
51%
46%
Table 2. Number of Medicare-only Beneficiaries, All Dually Eligible Individuals, Full-benefit Dually
Eligible Individuals, and Partial-benefit Dually Eligible Individuals Enrolled in Medicare Managed Care
in Each Year (in millions)
Year
Medicare-
Only
All Dually Eligible Beneficiaries
(Full- and Partial-benefit)
Full-benefit Dually
Eligible Beneficiaries
Partial-benefit Dually
Eligible Beneficiaries
2012
11.5
2.3
1.4
2013
12.5
2.6
1.6
2014
13.5
3.1
1.9
2015
14.3
3.5
2.2
2016
14.9
3.7
2.3
2017
15.9
4.1
2.6
2018
17.1
4.5
2.9
2019
18.3
5.0
3.2
2020
19.8
5.6
3.6
2021
21.5
6.5
4.3
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Appendix B: Managed Care Penetration among Full-benefit Dually Eligible Individuals
Table 3. Proportion of Full-benefit Dually Eligible Individuals Enrolled in Medicare Managed Care in
December Each Year, by Plan Type
Year
Medicare-
Medicaid
Plans
PACE
Medicare
Advantage
and Other
Total
2012
n/a
*
18%
18%
2013
*
*
20%
20%
2014
2%
*
22%
24%
2015
4%
*
22%
26%
2016
4%
*
23%
28%
2017
5%
*
26%
30%
2018
4%
*
29%
33%
2019
4%
*
32%
36%
2020
4%
*
36%
40%
2021
5%
*
41%
46%
*Less than 0.5%
Details may not sum to totals due to rounding.
Table 4. Number of Full-benefit Dually Eligible Individuals Enrolled in Medicare Managed Care in
December Each Year, by Plan Type, in millions
Year
Medicare-
Medicaid
Plans
PACE
Medicare
Advantage
and Other
Total
2012
n/a
*
1.3
1.4
2013
*
*
1.5
1.6
2014
0.2
*
1.7
1.9
2015
0.4
*
1.8
2.2
2016
0.4
*
1.9
2.3
2017
0.4
*
2.1
2.6
2018
0.4
*
2.4
2.9
2019
0.4
*
2.7
3.2
2020
0.4
0.1
3.2
3.6
2021
0.4
0.1
3.8
4.2
*Fewer than 50,000
Details may not sum to totals due to rounding.