A Profile of Medicare-Medicaid Enrollees (Dual Eligibles)

The 12.5 million people who are jointly enrolled in Medicare and Medicaid, Medicare-Medicaid enrollees (also referred to as dually-eligible beneficiaries or dual eligibles), receive their primary health insurance coverage through Medicare and some assistance from their state Medicaid program. Medicare is a federal program financed primarily by general revenues, payroll tax contributions, and premiums. Medicaid is the nation’s largest public health insurance program for low-income Americans and the primary payer for long-term services and supports. People enrolled in both Medicare and Medicaid comprise 17% of Medicare beneficiaries in traditional Medicare and 14% of Medicaid enrollees, but much higher shares of spending (33% of traditional Medicare spending and 32% of Medicaid spending).

While virtually all Medicare-Medicaid enrollees have low incomes and very modest savings, they are otherwise a heterogenous group in age, physical and mental health. Medicare-Medicaid enrollees include people ages 65 and over who are in relatively good health but have limited financial resources and people who at one time, may have had more financial resources, but spent their income and wealth on health or long-term care costs. They include people with lifelong intellectual and developmental disabilities who have always faced employment challenges and people under the age of 65 with robust work histories who left the labor force on account of significant physical or mental impairments.

Among the 12.5 million Medicare-Medicaid enrollees in 2020, most (73%) were “full-benefit” Medicare-Medicaid enrollees who were eligible for the full range of Medicaid benefits not otherwise covered by Medicare, such as long-term services and supports. Medicaid is jointly funded by states and the federal government. The federal government matches state spending for eligible beneficiaries and qualified services without a limit. The federal share of spending for most Medicaid enrollees is determined by a formula that provides a match of at least 50% and provides a higher match for states with lower per capita income relative to the national average. Most—but not all—full-benefit Medicare-Medicaid enrollees are also eligible for Medicare premium and cost-sharing assistance covered under the Medicare Savings Programs, which are administered by states. “Partial-benefit” Medicare-Medicaid enrollees are not eligible for full Medicaid benefits, but are eligible for assistance with Medicare premiums and, in many cases, cost sharing through the Medicare Savings Programs (see Box 1).

Box 1: How do Medicare Beneficiaries Become Eligible for Medicaid?

To be eligible for full Medicaid benefits, Medicare beneficiaries must meet states’ Medicaid eligibility criteria. States are required to cover Medicare beneficiaries who receive Supplemental Security Income, and may choose to cover additional groups such as people with income less than the federal poverty level and those who need long-term services and supports. Most, but not all, full-benefit Medicare-Medicaid enrollees are also eligible for Medicare premium and cost-sharing assistance covered under the Medicare Savings Programs, which are administered by states. Federal law defines minimum income and resource limits for each of the Medicare Savings Programs, which are updated annually by the Centers for Medicare and Medicaid Services (CMS). Programs vary by the type of assistance and state, but generally Medicare beneficiaries had to have income below $1,549 each month for an individual ($2,080 for a couple) and resources below $8,400 for an individual ($12,600 for a couple) in 2022. States can raise those limits above the federal floor to provide coverage to individuals who qualify based on the higher eligibility criteria for the Medicare Savings Programs.

This brief examines the demographic, socioeconomic, and health characteristics of Medicare-Medicaid enrollees using the 2020 Medicare Current Beneficiary Survey (see Methods for details). It highlights the diversity within the Medicare-Medicaid population and how Medicare-Medicaid enrollees differ from all other Medicare beneficiaries.

Key takeaways

• Among all Medicare-Medicaid enrollees, 87% had an income of less than $20,000, compared to 20% of all Medicare beneficiaries without Medicaid coverage.
• Almost 40% of Medicare-Medicaid enrollees were under age 65 and eligible for Medicare because they had received 24 months of Social Security Disability Insurance payments, compared to 8% of Medicare beneficiaries without Medicaid.
• Nearly half of all Medicare-Medicaid enrollees (49%) were people of color compared to less than 20% of Medicare beneficiaries without Medicaid coverage.
• More than four in 10 Medicare-Medicaid enrollees (44%) were in fair or poor health compared to 17% of Medicare beneficiaries without Medicaid. At the same time, 21% of full-benefit and 27% of partial-benefit Medicare-Medicaid enrollees reported excellent or very good health.
• Among Medicare-Medicaid enrollees, 48% had at least one limitation in activities of daily living (ADLs) compared to 23% of Medicare beneficiaries without Medicaid coverage. A larger share of full-benefit enrollees (40%) than partial-benefit enrollees (23%) had two or more limitations in ADLs.

What were the demographic and socioeconomic characteristics of Medicare-Medicaid enrollees?

Almost nine in ten Medicare-Medicaid enrollees (87%) lived on an annual income below $20,000 compared to one in five Medicare beneficiaries without Medicaid coverage (20%) (Figure 1, Income tab). While the vast majority of Medicare-Medicaid enrollees had relatively low incomes, partial-benefit Medicare-Medicaid enrollees had somewhat higher incomes compared to full-benefit Medicare-Medicaid enrollees, specifically a larger share of full-benefit than partial-benefit Medicare-Medicaid enrollees lived on incomes below $10,000 per year in 2020 (45% vs 27%).

Medicare-Medicaid enrollees with higher incomes may become eligible for Medicaid if they “spend down” their income due to large medical or long-term care expenses. Conversely, a small share of Medicare beneficiaries without Medicaid (3%) had an income of less than $10,000. These beneficiaries may not be enrolled in Medicaid because their assets exceeded the limit, they were unaware of the programs, or because they were unable to enroll on account of administrative burdens.

More than one in ten full-benefit Medicare-Medicaid enrollees (13%) lived in a long-term care nursing home or other institutional facility, compared to 1% of all Medicare beneficiaries without Medicaid coverage (Figure 1, Residence tab). More full-benefit Medicare-Medicaid enrollees living in institutional settings relative to all other Medicare beneficiaries likely reflects Medicaid eligibility provisions and the high costs of nursing facility care. The average cost of a private room in a nursing facility was over $108,000 in 2021. After spending their income and savings to pay for those costs, Medicare beneficiaries without Medicaid may become eligible for Medicaid coverage. In addition, Medicare beneficiaries who use long-term services and supports who meet other eligibility criteria  may qualify for Medicaid, if for example, they can demonstrate the need for an institutional level of care and meet other income and asset criteria.

Almost four in ten (37%) Medicare-Medicaid enrollees were under age 65 and qualified for Medicare on account of a long-term disability compared to fewer than one in ten Medicare beneficiaries without Medicaid (8%) (Figure 1, Age tab). People under age 65 are entitled to Medicare when they have received Social Security Disability Insurance benefits for 24 months. Medicare beneficiaries younger than age 65 differ from beneficiaries age 65 and older in terms of their medical conditions, service utilization, and income.

More than half (51%) of Medicare-Medicaid enrollees were people of color compared with 20% of Medicare beneficiaries without Medicaid. Overall, Medicare-Medicaid enrollees were more racially and ethnically diverse than Medicare beneficiaries without Medicaid: about half (49%) were White, 22% were Black, 20% were Hispanic, and 9% belong to other racial/ethnic groups (Figure 1, Race/Ethnicity tab). In contrast, 81% of Medicare beneficiaries without Medicaid were White and 19% were from communities of color. Full-benefit Medicare-Medicaid enrollees were less likely to be White and more likely to be Hispanic than partial-benefit Medicare-Medicaid enrollees.

What were the health characteristics of Medicare-Medicaid enrollees?

More than four in ten Medicare-Medicaid enrollees (44%) were in fair or poor health compared with 17% of Medicare beneficiaries without Medicaid coverage (Figure 2, Health Status tab). Conversely, nearly one-quarter (23%) reported being in excellent or very good health. Among Medicare-Medicaid enrollees there were differences in their reported health status: 46% of full-benefit Medicare-Medicaid enrollees and 40% of partial-benefit Medicare-Medicaid enrollees reported fair or poor health.

About one-quarter (26%) of Medicare-Medicaid enrollees had five or more chronic conditions, compared to 15% of Medicare beneficiaries without Medicaid coverage (Figure 2, Number of Chronic Conditions tab). Among Medicare-Medicaid enrollees, similar shares of full- and partial-benefit enrollees reported having five or more chronic conditions (26% for both groups), three or four chronic conditions (37% and 38%, respectively), one or two chronic conditions (30% for both groups), and no chronic conditions (7% and 6%, respectively).

Full-benefit Medicare-Medicaid enrollees were over twice as likely to have had a mental health condition than Medicare beneficiaries without Medicaid coverage. Half (50%) of full-benefit Medicare-Medicaid enrollees reported having a mental health condition compared with less than 25% of Medicare beneficiaries without Medicaid. The share of partial-benefit Medicare-Medicaid enrollees with a mental health condition (40%) was between the share of Medicare enrollees without Medicaid coverage and full-benefit enrollees (Figure 3, Mental Health Condition tab).

The share of beneficiaries with Alzheimer’s disease or other dementia was substantially higher among full-benefit Medicare-Medicaid enrollees than among partial-benefit Medicare-Medicaid enrollees or Medicare beneficiaries without Medicaid. Specifically, 11% of full-benefit Medicare-Medicaid enrollees had Alzheimer’s or other dementia compared to 3% of Medicare beneficiaries without Medicaid and 5% of partial-benefit Medicare-Medicaid enrollees.

About one in six full-benefit Medicare-Medicaid enrollees had an intellectual or developmental disability compared to just 5% of Medicare beneficiaries without Medicaid coverage. Among full-benefit Medicare-Medicaid enrollees, 16% had an intellectual or developmental disability compared to only 1% of Medicare beneficiaries without Medicaid coverage and 5% of partial-benefit Medicare-Medicaid enrollees (Figure 3, Intellectual/Developmental Disability tab).

Medicare-Medicaid enrollees were more likely than Medicare beneficiaries without Medicaid to report having a limitation in activities of daily living (ADL), which include eating, bathing, toileting, dressing, and functional mobility. Specifically, 48% of Medicare-Medicaid enrollees had at least one ADL limitation, compared to 23% of all Medicare beneficiaries without Medicaid coverage.

Among full-benefit Medicare-Medicaid enrollees, 40% reported having limitations in 2 or more ADLs, 13% had 1 limitation in an ADL, and just under half (48%) had no limitations in ADLs (Figure 3, Number of ADLs tab). In comparison, a smaller share (23%) of partial-benefit Medicare-Medicaid enrollees reported limitations in 2 or more ADLs, while somewhat higher shares had 1 limitation in an ADL (17%) or no limitations in ADLs (60%).

Conclusion

Overall, Medicare-Medicaid enrollees had lower incomes, were more racially and ethnically diverse, and were more likely to be in poorer health with greater health needs than Medicare beneficiaries without Medicaid coverage. Medicare-Medicaid enrollees are themselves a population with diverse needs and circumstances; while many live with serious physical and mental health challenges, nearly one in four Medicare-Medicaid enrollees reported being in excellent or very good health and more than half had no functional impairment. There were also differences between full- and partial-benefit enrollees. Full-benefit enrollees were more likely to live in an institutional setting, such as a long-term care nursing home, have had an intellectual or developmental disability, and more limitations in activities of daily living. Even within each of these groups there was variation in terms of Medicare-Medicaid enrollees’ demographic, socioeconomic, and health characteristics.

The heterogeneity of the Medicare-Medicaid population highlights the challenges policymakers face when developing targeted strategies to improve the coordination and management of care for these 12.5 million beneficiaries, while balancing the potential for more simplicity and efficiency against flexibility necessary to meet the diverse needs of this group.

Methods

Characteristics of Medicare-Medicaid Enrollees, based on Medicare Current Beneficiary Survey Data: Centers for Medicare & Medicaid Services’ Medicare Current Beneficiary Survey (MCBS), 2020 Survey File. Creating the Medicare Sample: All Medicare beneficiaries with either Part A and/or Part B for at least one day at any time during 2020. Additionally, only beneficiaries residing in the continental U.S. (48 states and the District of Columbia) are included. Alaska and Hawaii are not included among the states from which the sample is selected due to the high cost of data collection in those areas; however, they are included in control totals for weighting purposes. Beginning in 2017, sampling from Puerto Rico was discontinued. Beginning in 2018, all data collection in Puerto Rico was discontinued. We include all individuals living in institutions and in community settings. Identifying Full-Benefit and Partial- Benefit Medicare-Medicaid Enrollees: We identified Medicare-Medicaid enrollees if they had the relevant Medicaid coverage for any month of the year, based on state reporting requirements outlined in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Beneficiaries were assigned as full-benefit Medicare-Medicaid enrollee status if they had any of the following types of Medicaid benefits for any month of the year: Qualified Medicare Beneficiaries plus full Medicaid (QMB-Plus), Specified Low-Income Medicare Beneficiaries plus full Medicaid (SLMB-Plus), or Other full benefit dual eligible/Medicaid Only Dual Eligibles (Non-QMB, -SLMB, -QDWI, -QI). Beneficiaries were assigned as partial-benefit Medicare-Medicaid enrollee status if they had any of the following types of Medicaid benefits for any month of the year and were not identified as a full-benefit enrollee during any month: Qualified Medicare Beneficiaries without other Medicaid (QMB-only), Specified Low-Income Medicare Beneficiaries without other Medicaid (SLMB-only), or Qualifying Individuals (QI). Beneficiaries assigned as either full- or partial-benefit Medicare-Medicaid enrollee status were included in the “overall” sample of Medicare-Medicaid enrollees. All other Medicare beneficiaries in the sample were assigned as Medicare beneficiaries without Medicaid coverage. Comparing Across Subgroups: We determined whether differences in our estimates across groups (i.e., full-benefit Medicare-Medicaid enrollees vs. Medicare beneficiaries without Medicaid coverage) were significant at the p<0.05 level by conducting a two-proportion Z-test. All differences between Medicare-Medicaid enrollees (overall, as well as full-benefit and partial-benefit subgroups) and Medicare beneficiaries without Medicaid displayed in the figures and discussed in the text are significant. All differences between full- and partial-benefit Medicare-Medicaid enrollees are also significant with the following exceptions: share of enrollees who were Black, age 75-84, had income between $29,000 and $39,999, self-reported excellent, good or poor health, and the counts of chronic conditions.