KFF Health News won the 2023 George Polk Award for Medical Journalism for its year-long investigation with CBS News into the failure of FDA-approved medical devices that were suspected of contributing to thousands of injuries and patient deaths.

The George Polk Awards were established in 1949 by Long Island University to commemorate George Polk, a CBS correspondent murdered in 1948 while covering the Greek Civil War. The awards place a premium on investigative and enterprising reporting that gains attention and achieves results.

The investigation, “When Medical Devices Malfunction,“ brought to light deep flaws in FDA oversight of a series of devices, including:

• Artificial knee implants that wore out prematurely;
• Metal hip implants that snapped in two and led to urgent surgeries;
• Last-resort heart pumps that may have caused or contributed to thousands of patient deaths;
• Insulin pumps that are blamed for contributing to at least a dozen patient deaths; and,
• A dental device that lawsuits alleged caused catastrophic harm to teeth and jawbones.

“This investigation revealed the deeply significant, and sometimes deadly, impact of flawed devices and oversight, and is part of our continuing work across KFF to show how people are affected by health policy,” said Dr. Drew Altman, president and chief executive officer, KFF.

“When Medical Devices Malfunction“ was reported by Fred Schulte, an investigative reporter at KFF Health News, Holly K. Hacker, the data editor at KFF Health News, Daniel Chang, the Florida correspondent at KFF Health News, Brett Kelman, a correspondent at KFF Health News, Anna Werner, the national consumer investigative correspondent at CBS News, and Nicole Keller, consumer investigative producer at CBS. It is Schulte’s and Werner’s second Polk award.

About KFF Health News’ Partnership with CBS News

The reporting in “When Medical Devices Malfunction“ was done in partnership with CBS News to investigate the safety of devices suspected of causing patient harm and explore the FDA’s process for assuring patient safety. Reporters from KFF Health News and CBS reviewed FDA data and court records and conducted many interviews with patients, device manufactures, FDA officials, consumer advocates, and others.

The investigation stems from a broader editorial partnership between CBS News and KFF Health News. The editorial partnership also features regular appearances by Dr. Céline Gounder, KFF Health News’ senior fellow and editor-at-large for public health, on CBS News, the popular “Bill of the Month” series, in which KFF Health News editor-in-chief Elisabeth Rosenthal appears regularly on “CBS Mornings” to discuss surprising medical bills, and the KFF Health News “Health Minute,” a weekly feature for CBS News Radio stations that helps millions of listeners understand how developments in health care delivery and policy affect them.

About KFF and KFF Health News

KFF is the independent source for health policy research, polling, and journalism. Our mission is to serve as a nonpartisan source of information for policymakers, the media, the health policy community, and the public. KFF Health News is a national newsroom that produces in-depth and award-winning journalism about health issues and is one of the core operating programs at KFF. Other major KFF programs include Policy Analysis; KFF Polling and Survey Research; and KFF Social Impact Media, which conducts specialized public health information campaigns. A new program on Health Misinformation and Trust is under development.

The data is available for download.

Note: For the latest information on states with approved and pending waivers to extend multi-year continuous eligibility for children, view our Section 1115 tracker “Key Themes Maps.“

The pandemic continuous enrollment provision and other research show that continuous eligibility reduces Medicaid disenrollment and “churn” rates and helps to ensure stable coverage. Guaranteeing 12-month continuous coverage for children has long been an option in Medicaid and CHIP without a waiver, but not for adults. The Consolidated Appropriations Act required all states to implement 12-month continuous eligibility for children beginning on January 1, 2024. As many Medicaid enrollees are currently experiencing disruptions in coverage as a result of the Medicaid unwinding, a number of states are pursuing strategies to help promote continuity of coverage, including through unwinding waivers and Section 1115 demonstration waivers. This Waiver Watch summarizes approved and pending Section 1115 waivers with continuous eligibility provisions for children and adults in Medicaid.

What is continuous eligibility?

States are required to provide 12-month continuous eligibility for children in Medicaid and CHIP. Continuous eligibility generally allows individuals to remain enrolled for a specific period even if there are fluctuations in income. States have long had the option to provide 12 months of continuous eligibility to children (under age 19) without a waiver, and many states (23 as of January 2023) had taken up that option for all children in Medicaid and CHIP (additional states had adopted 12-month continuous eligibility for only some children or only children in CHIP). However, the Consolidated Appropriations Act required all states to implement 12-month continuous eligibility for all children in Medicaid and CHIP beginning on January 1, 2024. Additional guidance issued on October 27, 2023 prohibits states from terminating coverage of children enrolled in CHIP for failure to pay premiums. Under the previous 12-month continuous eligibility option, states were permitted to disenroll children in CHIP during the continuous eligibility period if a family did not pay their premiums; this exception to continuous eligibility was not available in Medicaid. On February 1, 2024, the state of Florida filed a lawsuit against HHS challenging the implementation of the law, asserting states should be allowed to terminate CHIP coverage (during the 12-month period) when premium payments are not made.

Under current law, states cannot provide continuous eligibility for adults without a Section 1115 waiver submitted to the federal government. States cannot require a renewal process for Medicaid coverage for adults who are eligible based on income more than once every 12 months. While states may conduct renewals for individuals who qualify for Medicaid based on age or disability more than once every 12 months, most states conduct annual renewals for these groups. However, because states cannot guarantee continuous eligibility for adults absent a waiver, adults may lose coverage if there are “changes in circumstance,” including changes in family income, during the year. Enrollees are required to report changes in circumstances, and some states conduct periodic electronic data matches between renewal periods to identify changes in circumstance.

Continuous eligibility has been shown to reduce Medicaid disenrollment and “churn” rates. Churn occurs when individuals temporarily lose Medicaid coverage and then re-enroll within a short period of time suggesting they are experiencing short-term changes in income or difficulty completing the renewal process. When individuals churn on and off coverage, the gaps in coverage may limit access to care or lead to delays in getting needed care, which can be especially problematic for young children who receive frequent screenings and check-ups. Research has found continuous eligibility for Medicaid is associated with improved child health. While continuous eligibility increases coverage costs due to longer average eligibility periods, there are also administrative costs associated with disenrolling individuals and then subsequently processing new applications.

How are states using 1115 waivers to provide extended continuous eligibility for children?

As of February 15, 2024, three states have approved Section 1115 demonstration waivers to provide multi-year continuous eligibility to children (Table 1). Section 1115 waivers allow states to obtain federal approval to operate Medicaid programs in ways that differ from federal standards and requirements. In September 2022, CMS approved Oregon’s waiver to implement continuous eligibility for children from birth to age six as well as 24 months of continuous eligibility for nearly all enrollees ages six and older. Since then, CMS has approved multi-year continuous eligibility requests for children in Washington and New Mexico. Hawaii, Minnesota, North Carolina, and Pennsylvania have requests pending with CMS.

A number of states are developing waivers to provide multi-year continuous eligibility to children. Several states have waiver proposals under development that have recently been released for state-level public comment (California, Colorado, and New York) that include multi-year continuous eligibility for children (Table 1). Other tracking shows state activity, including legislation directing the state Medicaid agency to seek approval for multi-year continuous eligibility for children, in Illinois, Ohio and the District of Columbia. In December 2023, growing concern over loss of Medicaid coverage for children prompted federal officials to issue additional guidance with strategies to protect coverage; one strategy CMS highlighted in its guidance is providing multi-year continuous eligibility for children through Section 1115 demonstration authority.

What options do states have to provide continuous eligibility for adults?

As of February 15, 2024, five states have approved Section 1115 waivers to provide varying lengths of continuous eligibility to certain adults (Table 2). Oregon provides 24 months of continuous eligibility to nearly all enrollees over age six. New York and New Jersey provide 12-month continuous eligibility to all income-eligible Medicaid adults. Kansas provides 12-month continuous eligibility to parents and caretaker relatives. Massachusetts provides 12-month continuous eligibility for individuals following release from a correctional institution and 24-month continuous eligibility for individuals under age 65 experiencing homelessness for at least 6 months; however, the state is seeking CMS approval to expand 12-month continuous eligibility to all adults (including those eligible based on income, age, or disability status) and 24 months of continuous eligibility to all adults experiencing homelessness. Minnesota is seeking to provide 12-month continuous eligibility to young adults ages 19 and 20, and Pennsylvania is seeking to provide 12-month continuous eligibility to individuals that qualify for proposed reentry services following release from a correctional facility.

Looking Ahead

Experience during the pandemic demonstrated that continuous enrollment can ensure stable coverage and reduce churn. While increased enrollment may result in increased overall costs, the policy can also improve health outcomes and potentially lead to some longer-term savings due to less fragmented care. While the unwinding of the pandemic-era continuous enrollment provision is leading to high rates of procedural disenrollments and is expected to increase the number of people who are uninsured longer term, mandatory 12-month continuous eligibility for children as well as new continuous eligibility policies that some states are pursuing through 1115 waivers can help to provide more stable coverage once the unwinding period ends.

In this JAMA Health Forum column,  Larry Levitt, KFF’s Executive Vice President for Health Policy, explores what a second Trump presidency would mean for health care based on President Trump’s record and remarks, and concludes that a new term likely would result in efforts to weaken the Affordable Care Act, reduce federal Medicaid costs, restrict abortion access to abortion, and scale back benefits for immigrants.

Fewer nursing facility residents and staff are getting COVID-19 vaccines, according to a new KFF analysis of federal data. Only 38% of residents and 15% of staff have received the latest vaccine. In comparison, 50% of residents and 22% of staff received updated vaccines in 2022 and 87% of residents and 88% of staff completed the initial vaccination series.

The percentage of residents who received the latest COVID-19 vaccine varies by state and type of facility. Vaccination rates range from 20% in Arizona to 63% in Vermont and North Dakota and were higher in nonprofit facilities (46%) than in for-profit (35%) or government (43%) facilities. Nursing staff had less variation and lower vaccination rates across states and in all facilities.

Residents’ and staff vaccination rates have declined with the release of each new COVID-19 shot for a variety of reasons, including fewer federal initiatives aimed at increasing vaccinations, the end of vaccine mandates for health care workers, and declining concerns about COVID-19 risks. Recent KFF polling shows that more than half of previously vaccinated adults are not worried about getting COVID-19.

Variation in nursing facility vaccine rates across states may be affected by several factors, including ownership patterns and partisanship, with higher rates in states that have more non-profit facilities and states that voted for President Biden in 2020, as well as whether facilities have established successful vaccination programs.

Keeping 2 million nursing facility staff and 1.2 million residents current on their COVID-19 vaccines is one tool for reducing deaths from COVID-19 as the virus continues to evolve. KFF analysis found that despite over one-fifth of all U.S. COVID-19 deaths occurring in long-term care facilities, as of January 14, 2024, only 38% of residents and 15% of staff were “up-to-date” with their COVID-19 vaccines, which the CDC defines as having received the updated Fall 2023 vaccine. Those rates are lower than uptake was for the 2022 vaccine. This data note also finds lower uptake rates for for-profit facilities and state uptake rates that vary from 20% to 63%. Data for this analysis include 14,318 nursing facilities (96% of all nursing facilities, home to 1.2 million residents) that had reported COVID-19 vaccination data as of January 21, 2024.

Uptake of the most recent COVID-19 vaccine is lower among nursing facility residents and staff than uptake was for the fall 2022 vaccine: Only 38% of residents and 15% of staff have received the new vaccine (Figure 1). In comparison, at the same point in time last year, 50% of residents and 22% of staff had received the updated vaccine. Those rates represent the share that received the newly available COVID-19 vaccines, 18 weeks after each shot was made available to the public. These rates are much lower than the 87% of residents and 88% of staff who received their primary vaccination series when measured in September 2022. On January 1, 2024, the CDC changed the way it collects data to calculate the percent of staff who are up to date with their COVID-19 vaccination. CMS reports that it may take facilities some time to adapt to the new methodology.

Uptake of the current COVID-19 vaccine is higher in non-profit facilities than in for-profit or government facilities (Figure 2). The percentage of nursing facility residents who received the updated vaccine is 46% in non-profit facilities compared with 35% in for-profit facilities and 43% in government facilities. Uptake of the fall 2022 vaccine was also highest in non-profit facilities and lowest in for-profit facilities. Rates of vaccine uptake for nursing facility staff were low in all types of facilities with minimal variation across facility types (data not shown).

The percentage of nursing facility residents who received the latest COVID-19 vaccine ranges from 20% in Arizona to 63% in Vermont and North Dakota (Figure 3). In eleven states, half or more of nursing facility residents received the newest vaccine while in two states, 25% or fewer have received the most recent vaccine. Uptake among staff of the most recent vaccine ranges from 5% in Arkansas to 51% in Washington D.C. In 42 states, fewer than 20% of staff have received the most recent vaccine. There are a number of factors that may contribute to the variation in nursing facility vaccine uptake across states including ownership patterns and partisanship, with higher rates in states that have more non-profit facilities and states that voted for President Biden in 2020. Other factors include whether facilities have established programs to keep residents current on their vaccines and the success of those various programs. Additionally, some state variation in staff rates may be attributed to variation in how facilities are adapting to new CMS reporting methodology for staff vaccinations.

Federal vaccine clinics contributed to high initial vaccination rates among nursing facility residents, but without ongoing federal initiatives, uptake of vaccines among nursing facility residents may remain low and vary across facilities. Earlier KFF analysis found that nearly 90% of residents completed the initial COVID-19 vaccination series. High take-up of the primary vaccine series stems from high death rates among nursing facility residents, which contributed to a fear of contracting COVID-19, and a concerted policy effort to vaccinate nursing facility residents, including through federally supported on-site vaccination clinics. According to AARP, federal supports have ended and long-term care facilities now coordinate their own COVID-19 vaccination programs, contributing to greater variation across facilities and lower overall rates.

Recent KFF polling shows that over half of previously vaccinated adults are not worried about getting COVID-19, suggesting that uptake of vaccines among nursing facility staff may remain low in the absence of federal mandates. Among nursing facility staff, initial take-up of COVID-19 vaccines was low until a health care worker vaccination mandate required providers that participate in Medicare and/or Medicaid to be vaccinated. This mandate was not updated to include follow-up vaccines, which may contribute to lower uptake of new vaccines among staff, particularly as concern about contracting COVID-19 drops among the U.S, population more broadly.

As winter viruses circulate, COVID-19 vaccines may help decrease sickness and preventable deaths among nursing facility residents and staff. Though people living and working in nursing facilities have likely built some immunity against COVID-19 through prior vaccinations and natural immunity, periodic vaccines have been shown to decrease mortality and increase antibody concentrations among nursing facility residents. For older adults—who constitute most people who use nursing facilities—the risks of COVID-19 may be seven times higher than that of the flu. The CDC finds that 72% of residents had received the flu vaccine as of December 10, 2023, among the small number of nursing facilities that had reported such data, a rate that is nearly twice that of the most recent COVID-19 vaccine. Beyond the flu and COVID-19, RSV is another high-risk respiratory virus. Although there is a new vaccine for RSV, uptake of the new vaccine among nursing facility residents has been hampered by shortages of RSV vaccines and the prioritization of the vaccine for infants and high-risk children. Increasing access to all vaccinations for this population may be a key strategy to preventing respiratory illnesses.

People with medical debt are much more likely than those without such debt to show other signs of financial vulnerability, like having no “rainy day” fund, overdrawing a checking account, or relying on costly loans, according to a new KFF analysis of national survey data.

Medical debt remains a significant issue in the U.S., including among people with health insurance. In 2021, 23% of U.S. adults had one or more unpaid and past due bills from a medical service provider.

KFF’s 2022 Health Care Debt Survey found similar results: Among adults, 24% say they had medical or dental bills that were past due or that they could not pay, and a total of 41% had some type of health care debt, including on credit cards or owed to family members.

Medical debt and other forms of financial instability affect people and households across the income spectrum and can cause individuals to forgo needed care. In its award-winning series, “Diagnosis: Debt”, KFF Health News examined the epidemic of medical debt that has become a defining feature of the U.S. health care system.

The Consumer Financial Protection Bureau is expected to release requirements that remove medical debt from credit reports and could crack down on certain debt collection practices. Some states and localities have also bought or are seeking to buy their residents’ medical debt, in part with remaining COVID relief funds.

KFF’s new analysis relies on data from the 2021 National Financial Capabilities Survey. The survey uses information from more than 27,000 adults in each state and D.C.

This analysis of government data finds that people with medical debt are much more likely to have other forms of financial distress than those without medical debt, like having no “rainy day” fund, overdrawing a checking account, or relying on costly loans.

Medical debt is associated with financial vulnerability across a range of other indicators and can cause people to delay or forgo needed medical care due to cost.

The analysis relies on data from the 2021 National Financial Capabilities Survey. The survey uses information from more than 27,000 adults in each state and D.C.

The analysis is available through the KFF-Peterson Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

This analysis of government data estimates that people in the United States owe at least $220 billion in medical debt. Approximately 14 million people (6% of adults) in the U.S. owe over $1,000 in medical debt and about 3 million people (1% of adults) owe medical debt of more than $10,000.

The share of adults with medical debt varies considerably across the U.S. Hawaii (2.3%) and D.C. (2.7%) have the lowest share of adults with medical debt. States with the highest share of adults with medical debt include South Dakota (17.7%), Mississippi (15.2%), North Carolina (13.4%), West Virginia (13.3%), and Georgia (12.7%).

The analysis is based on data from the 2021 Survey of Income and Program Participation, a nationally representative survey that asks every adult in a household whether they owed money for medical bills and how much they owe.

The report also examines variations in medical debt by age, race and ethnicity, health status, and for people with a disability.

The analysis is available through the KFF-Peterson Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

About 12.9 million people received health coverage under both Medicare and Medicaid in 2021. Medicare-Medicaid enrollees, known as dual-eligible individuals, are a diverse group, as nearly half are people of color and nearly 40% are under age 65. However, this group of people share some common characteristics, such as limited financial means and health care needs that are more wide-ranging and complex than the average Medicare enrollee.

Prior KFF research has described the complex landscape of coverage options available to dual-eligible individuals when enrolling in Medicare and Medicaid. Medicare, the primary source of health insurance coverage for dual-eligible individuals, may be provided under traditional Medicare or a Medicare Advantage plan. Medicaid, which typically wraps around Medicare, covers the cost of Medicare premiums and in many cases, cost sharing assistance. Full dual-eligible individuals are also eligible for benefits not otherwise covered by Medicare, such as long-term services and supports. Dual-eligible individuals may receive Medicaid benefits through fee-for-service or managed care, and coverage and eligibility vary by state. Separate eligibility requirements, benefits, and rules for Medicare and Medicaid sometimes contribute to what has been described as a “fragmented and disjointed system of care for dual eligibles” which may lead to difficulty in navigating care among dual-eligible individuals.

In 2023, 5.2 million dual-eligible individuals were enrolled in a Medicare Advantage plan designed specifically for dual-eligible individuals, known as Dual-Eligible Special Needs Plans (D-SNPs). D-SNPs are required to provide greater coordination of Medicare and Medicaid benefits than other Medicare Advantage plans to improve coordination across programs and patient outcomes. D-SNPs typically provide benefits not otherwise available in traditional Medicare and generally do not charge a premium.

This brief highlights 10 things to know about D-SNPs, including national and state enrollment trends, plan availability, insurer participation, benefits, and prior authorization rates and denials, based on data from various sources (see methods for details). While D-SNPs can help with coordination for dual-eligibles in Medicare and Medicaid and they are growing rapidly, fewer than one in ten D-SNP enrollees were in fully integrated dual eligible (FIDE) special needs plans (SNPs), raising questions about how well coverage and care is being coordinated between Medicare and Medicaid. In addition, gaps in data make it difficult to assess the quality of D-SNPs, prior authorization rates and denials by type of service, and the extent to which extra benefits are used.

1. About 3 in 10 (29%) dual-eligible individuals enrolled in D-SNPs in 2021.

In 2021, nearly 3 in 10 (29%) dual-eligible individuals were enrolled in a D-SNP. Between 2010 and 2021, the share of dual-eligible individuals enrolled in D-SNPs nearly tripled from 11% to 29%.

As of 2023, most D-SNP enrollees (57%) were in coordination-only (CO) plans that are required to provide a minimum level of coordination between Medicare and Medicaid but are not fully integrated within the same plan. Another 35% of D-SNP enrollees were in what is known as highly integrated dual eligible (HIDE) SNPs that meet the requirements of CO plans and also require coverage of long-term services and supports and behavioral health. The remaining 8% were in plans that were fully integrated dual eligible (FIDE) special needs plans (SNPs), which coordinate care for dual-eligible individuals within a single managed care organization.

2. The share of dual-eligible individuals enrolled in D-SNPs varies by state, ranging from 5% (Nevada) to 58% (Hawaii) in 2021.

In 2021, D-SNP enrollment as a share of dual-eligible individuals ranged from 5% in Nevada to 58% in Hawaii, as compared to 29% nationwide. In seven states, 40% or more of all dual-eligible individuals were enrolled in D-SNPs: Alabama (42%), New York (42%), Florida (46%), Tennessee (46%), Arizona (47%), and Hawaii (58%), as well as in Puerto Rico (98%, not shown). Conversely, less than 10% of dual-eligible individuals were enrolled in D-SNPs in Nevada (5%), where D-SNPs were first available in 2021, and Montana (8%).

The share of dual-eligible individuals enrolled in D-SNPs more than doubled in 19 states between 2018 and 2021. States with relatively low D-SNP enrollment relative to the dual-eligible population in 2018, such as Oklahoma, Iowa, and West Virginia, had the highest percentage growth in share of dual-eligible individuals enrolled in D-SNPs between 2018 and 2021. For example, the share of dual-eligible individuals enrolled in D-SNPs in Oklahoma increased from 1% in 2018 to 12% in 2021. Several states, such as Arizona (45% vs. 47%), California (10% vs. 10%), Hawaii (57 vs. 58%), Massachusetts (16% vs. 19%), and Minnesota (30% vs. 34%), maintained similar shares of dual-eligible individuals enrolled in D-SNPs between 2018 and 2021. New Mexico, Oregon, and Utah were the only states where a smaller share of dual-eligible individuals enrolled in D-SNPs in 2021 compared to 2018. Insurers in Alaska, Illinois, New Hampshire, Wyoming, Vermont, North Dakota, and South Dakota did not offer D-SNPs in 2018 or 2021. Overall, Medicare Advantage enrollment in these states tends to be lower than the national average, partially explaining the relatively low enrollment among dual-eligible individuals in D-SNPs.

Differences in D-SNP enrollment across states may be reflective of several factors, including variation in: state-level policies pertaining to D-SNP enrollment, demographic characteristics of the dual-eligible population in the state, firm strategy, and the ability to establish care networks for dual-eligible individuals.

3. Within states, the share of dual-eligible individuals enrolled in a D-SNP varied across counties in 2021.

Within states, D-SNP enrollment among dual-eligible individuals often varies by county. For example, in Northern California, 20% of dual-eligible individuals in San Francisco County were enrolled in D-SNPs in 2021, compared to only 5% in nearby Santa Clara County. Although there was roughly the same number of dual-eligible individuals in Alameda and Sacramento Counties in 2021, only 16% of dual-eligible individuals in Alameda County were enrolled in D-SNPs, while over one-third (34%) of dual-eligible individuals in Sacramento County were enrolled in D-SNPs. In Florida, the share of dual-eligible individuals in Orlando was 54% (Pasco County) compared to 64% in nearby Tampa (Osceola County). However, in counties in the Florida Panhandle, the share of dual-eligible individuals enrolled in D-SNPs was much lower: 24% in Jackson County and 45% in adjacent Gadsden County. In Puerto Rico (not shown), enrollment of dual-eligible individuals in D-SNPs is nearly universal.

Variations in D-SNP enrollment at the county level may be attributed to several factors, such as rurality and Medicare payment rates.

4. More than 9 in 10 dual-eligible individuals (92%) lived in a county that offered at least one D-SNP in 2022.

More than 9 in 10 (92%) dual-eligible individuals could choose from at least one D-SNP when selecting coverage for 2022, up from 86% in the 2018 plan year. Most of the remaining 8% of dual-eligible individuals without access to a D-SNP lived in the 5 states where D-SNPs were not available in 2022 (Illinois, New Hampshire, South Dakota, Vermont, and Alaska).

5. The average dual-eligible individual could choose from 10 D-SNPs in 2022.

The average dual-eligible individual could choose from 10 D-SNPs in 2022 – more D-SNPs than in any previous year. The number of D-SNPs available to the average dual-eligible individual has more than doubled since 2011. While the average dual-eligible individual could choose from 10 D-SNPs, plan availability varied widely by county in 2022. For example, dual-eligible individuals in most counties composing metropolitan New York City had access to up to 40 D-SNP options, while dual-eligible individuals in neighboring Suffolk County could choose from 17 plans. Dual-eligible individuals in states such as Wyoming and Montana were able to access only one D-SNP. Dual-eligible individuals in Illinois, North Dakota, New Hampshire, Vermont, and Alaska did not have access to a D-SNP in 2022 (and will also not have access to a D-SNP in 2024).

6. About half (52%) of D-SNP enrollees were in UnitedHealthcare or Humana plans in 2023.

UnitedHealthcare and Humana were the dominant providers of D-SNPs in 2023, accounting for 52% of total D-SNP enrollment. Enrollment in UnitedHealthcare plans alone accounted for nearly two-fifths of total D-SNP enrollment (37%) and exceeded combined enrollment of BCBS, Centene, Elevance Non-Blue, CVS Health, Kaiser Permanente, and Cigna (31%) in 2023.

Between 2018 and 2023, the share of enrollees in plans offered by smaller firms has declined from 27% to 17%. Between 2018 and 2023, the share of D-SNP enrollees choosing plans offered by Kaiser Permanente, Cigna, Centene, BCBS, and Elevance Non-Blue declined, while the share of enrollees choosing UnitedHealthcare, CVS Health, and Humana plans increased.

7. Every major insurer increased the number of D-SNP offerings between 2018 and 2024.

In plan year 2024, insurers are offering 851 plans, more than double the number offered in plan year 2018 (401). The growth in offerings between plan years 2018 and 2024 can be attributed to insurers increasing offerings in existing counties and expanding the number counties in which D-SNPs are offered.

Eight major insurers are offering 75% (638) of plans in 2024, up from 68% in plan year 2018. The remaining 25% (213) of plans are offered by smaller insurers. In plan year 2024, CVS will offer 105 plans, an increase of 98 plans since the 2018 plan year. This represents the largest growth in plan offerings among the major insurers. Kaiser Permanente will offer 10 plans, an increase of 5 plans since the 2018 plan year. This represents the smallest growth in plan offerings among major insurers.

One firm, Florida Complete Care, is entering the D-SNP market in 2024 (though it has offered other types of SNPs in prior years), while 5 firms that offered D-SNPs (Ascension, Health Choice Generations Utah, AgeWell New York, Essence Healthcare, and Vantage Health Plan) are exiting the D-SNP market. This differs from prior KFF analysis which examines entries and exits for the overall Medicare Advantage market.

8. D-SNPs are more likely than other Medicare Advantage plans to offer some extra benefits such as over the counter benefits and meal benefits.

The share of D-SNPs offering eye exams and/or eyeglasses (96%), dental care (95%), fitness benefits (94%), or hearing exams and/or aids (92%) was nearly universal for enrollees in D-SNPs as well as individual Medicare Advantage plans in 2024 (Figure 8). However, D-SNPs are more likely than individual Medicare Advantage plans to offer over the counter benefits (96% vs. 85%), meal benefits (86% vs. 72%), bathroom safety devices (32% vs. 22%), and in-home support services (23% vs. 9%). D-SNPs are also more likely to offer transportation services than other Medicare Advantage plans (88% vs. 36%). Many of the additional benefits may be covered by Medicaid as “Medicaid wraparound services.” States are required to cover non-emergency medical transportation (NEMT), all states provide some home-based care (including meals, bathroom safety, or in-home supports), and many states cover some dental and vision services. D-SNPs may expand upon the services offered through Medicaid and it is unknown to what extent the D-SNP offerings supplement the Medicaid services for specific states or plans.

9. In 2021, dual-eligible individuals enrolled in a plan in a D-SNP-only contract were subject to one prior authorization request, on average.

CMS publishes prior authorization data by contract and not by plan type, which makes it impossible to document the total number of prior authorization requests or denials for D-SNP enrollees. This analysis, therefore, relies on data about contracts containing only D-SNPs, which account for about 19% of total D-SNP enrollment. Most D-SNP enrollees (81%) are in plans that are in a contract with other Medicare plan types, which means CMS does not collect or publish prior authorization data for most D-SNP enrollees.

On average, firms with contracts containing only D-SNPs received one prior authorization request per beneficiary in 2021, as compared to previous KFF analysis showing 1.5 prior authorization requests per enrollee for all Medicare Advantage plans, although that estimate included contracts that included both D-SNPs and other plans. This is somewhat surprising, considering dual-eligible individuals generally utilize more health care services than the average Medicare beneficiary.

Unlike other insurers, CVS had more prior authorization requests for enrollees in D-SNP-only contracts than for enrollees in all Medicare Advantage contracts. Prior authorizations ranged across firms from less than one per beneficiary (UnitedHealthcare) to 2.2 per beneficiary (BCBS) for contracts containing only D-SNPs.

10.Despite fewer prior authorizations in D-SNP-only plans compared to all Medicare Advantage plans, the rate of denials was twice as high.

In 2021, firms with contracts containing only D-SNPs received nearly 670,000 prior authorization requests, 12% of which were denied. This is double the denial rate for all Medicare Advantage plans (6%), according to previous KFF analysis. The rate of prior authorization request denials ranged from 5% (Humana) to 15% (CVS Health and Centene) among contracts containing only D-SNPs. Nearly 7% of just over 80,000 denials were appealed, compared to 11% of denials for all Medicare Advantage plans. Just over two-thirds (68%) of those appeals were resolved favorably, in contrast to prior KFF analysis that found over 82% of appeals for all Medicare Advantage contracts were resolved favorably.

Previous KFF analysis of Medicare Advantage prior authorization data revealed an inverse relationship between the insurer’s volume of prior authorization requests and share of requests that were denied. This relationship among D-SNP-only contracts holds for some firms, such as UnitedHealthcare and Humana, but not others. For example, Centene D-SNP-only contracts received on average 1.7 requests per enrollee, higher than the overall rate of one prior authorization request and denied 15% of those requests compared to 12% overall. As with prior authorization data, denial rates are collected and reported at the contract level, which means denial rates in D-SNP-only contracts represent a fraction of individuals enrolled in D-SNPs.

Discussion

In 2021, nearly 3 in 10 (29%) dual-eligible individuals enrolled in D-SNPs, an increase from 20% in 2018. Growth in D-SNP enrollment may be driven by several factors. D-SNPs may be attractive to dual-eligible individuals due to the availability of extra benefits, including benefits that are offered more frequently in D-SNPs than Medicare Advantage plans for general enrollment, such as over the counter benefits and meals. There is also strong interest in D-SNPs among insurers, given relatively high margins. Since 2018, more insurers have offered D-SNPs and larger insurers have offered more plans. Growth in enrollment may be due to some extent to the automatic enrollment of some individuals into D-SNPs. In 2022, more than 9 in 10 dual-eligible individuals (92%) lived in counties where insurers offered at least one D-SNP, with an average of 10 D-SNPs offered per dual-eligible individual, compared to 6 plans in 2018.

While enrollment and plan availability continue to grow, it is not clear how well D-SNPs coordinate with Medicaid to provide the full range of benefits to dual-eligible enrollees. Fewer than one in ten D-SNP enrollees are in fully integrated plans.

Relatedly, little is known about the quality of D-SNPs. Because quality ratings are reported at the contract level, rather than the plan level, it is not possible to assess the quality of D-SNPs that are included in contracts with other plans, affecting most D-SNP enrollees. Most D-SNP enrollees (81%) are in plans that are part of a contract with other plans, which means the quality ratings are at the contract level, not of their specific plan. Further, MedPAC has raised concerns that the current quality measures are not sufficient to adequately assess care delivery in D-SNPs. Early attempts at quality measurements have produced mixed results, with some reporting little variation in quality measurements between plans and others reporting little difference in care quality between D-SNPs and other methods of care for dual-eligible individuals.

Lack of data transparency also contributes to limited understanding of the impact of prior authorization requirements and denials for dual-eligible individuals enrolled in D-SNPs. KFF’s analysis suggests that contracts containing D-SNPs (but no other plans) deny prior authorization requests at a much higher rate than Medicare Advantage plans overall, even though firms with contracts containing only D-SNPs received few authorization requests per enrollee. Again, because prior authorization requests and denials are reported at the contract level, it is not possible to document the number of prior authorization requests for D-SNP enrollees overall or per person, or denial rates.

Further, although most plans offer some extra benefits to D-SNP enrollees, it is not clear how often D-SNP enrollees take advantage of these extra benefits, whether insurers offer adequate networks to access these services, and whether they are of value to a population with such diverse health needs. A recent proposed rule by the Biden Administration would require insurance providers to periodically notify D-SNP enrollees if they are not utilizing supplemental benefits offered by their plan, but there is an absence of comprehensive data pertaining to the use of supplemental benefits among D-SNP and other Medicare Advantage enrollees, according to KFF. In addition, there is some concern among advocates and policymakers about marketing benefits, such as transportation, dental, and vision when dual-eligible individuals may already be eligible for these services through Medicaid. Given the significant needs of the dual-eligible population, and incentives for rapid growth in D-SNP enrollment, including proposed policy changes to institute Special Enrollment Periods to increase D-SNP participation, greater insight into the experiences of D-SNP enrollees would be valuable for beneficiaries and policymakers.