In 2020, KFF estimates that 4.2 million people used Medicaid long-term services and supports (LTSS) delivered in home and community settings and 1.6 million used LTSS delivered in institutional settings (Figure 1). LTSS encompass the broad range of paid and unpaid medical and personal care services that assist with activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medication, and housekeeping). They are provided to people who need such services because of aging, chronic illness, or disability and may be provided in institutional settings such as nursing facilities or in people’s homes and the community. Services provided in non-institutional settings are usually referred to as home- and community-based services (HCBS) and include a wide range of services such as adult daycare, home health, personal care, transportation, and supported employment. In 2020, Medicaid was the primary payer for LTSS, covering over half of all LTSS spending in in the U.S. Despite Medicaid’s significant role in funding LTSS in the U.S., eligibility for Medicaid LTSS is complex and varies widely by state. This data note provides an overview of Medicaid coverage of LTSS, KFF estimates of how many Medicaid enrollees used LTSS in 2020, how much Medicaid spent on enrollees who used LTSS, and policy issues to watch in the coming years. Key takeaways include:

• In 2020, there were 5.6 million people who used Medicaid LTSS, of which 4.0 million (72%) used only HCBS, 1.4 million (24%) used only institutional care, and 0.2 million used both (4%) (Figure 1). The share of people using Medicaid LTSS only in home and community-based settings ranged from 45% in Maine to 94% in North Carolina (Figure 2).
• Medicaid spending per-person was nearly nine times higher for people who used LTSS than for those who did not use LTSS ($38,769 vs. $4,480), with particularly high spending for people who used institutional LTSS (Figure 4).
• People who used Medicaid LTSS comprised 6% of Medicaid enrollment but 37% of federal and state Medicaid spending, reflecting the generally high cost of LTSS and more extensive health needs that lead to higher use of other health care services and drugs (Figure 5).

KFF’s estimates differ from the number of people using Medicaid LTSS reported by the Centers for Medicare & Medicaid Services (CMS), which found that about 11 million Medicaid enrollees used LTSS in 2019. CMS counts are higher than KFF counts because CMS defines LTSS more broadly and includes enrollees who may only use LTSS on a single day. CMS counts include people who are using services such as behavioral health, rehabilitation, health homes, and case management, but no other LTSS, whereas KFF only included enrollees if they were using the services identified in the data note below. CMS also counted people as using LTSS if they had one or more claims for a service, but KFF’s definition aims to capture only people who are using the services on an ongoing basis.

What are Medicaid Long-Term Services and Supports?

Medicaid LTSS are generally classified by the location in which they are provided: either in an institutional setting or in home- and community-based settings, also known as HCBS. Institutional care includes care provided in a nursing facility, which is a mandatory Medicaid benefit, and care provided in an intermediate care facility for people with intellectual disabilities, which is an optional benefit that all states currently choose to cover. HCBS include a broader range of benefits, which are all optional except for home health care. HCBS first became available as a Medicaid “waiver” option and in that capacity, services were generally available to certain types of Medicaid enrollees such as those with intellectual disabilities or those with physical disabilities.

In the last 20 years, several new authorities have been created, allowing states to also offer HCBS through the Medicaid state plan (see Appendix Table 1 for a list of HCBS authorities). If services are provided through a state plan, they must be offered to all eligible individuals. In contrast, services provided under waivers, such as 1115s or 1915(c)s, may be restricted to specific groups based on geographic region, income, or type of disability. Waivers may also include a wider range of service types than can be provided under state plans. Historically, Medicaid spent more money on LTSS in institutional settings than on LTSS delivered in home and community-based settings, but initiatives to balance HCBS and institutional care have changed that trend. Since 2013, Medicaid has spent more on HCBS than institutional care.

How Many People Used Medicaid LTSS in 2020?

In 2020, there were 5.6 million people who used Medicaid LTSS, of which 4.0 million (72%) used only HCBS, 1.4 million (24%) used only institutional care, and 0.2 million used both (4%) (Figure 1). These counts and shares did not change notably between 2018 and 2020. KFF’s current count of the number of people using Medicaid LTSS is lower than the number of people using LTSS reported by the Centers for Medicare & Medicaid Services (CMS) because KFF only counted people as using LTSS if they used institutional care or HCBS on an ongoing basis. CMS included a broader set of services in their definition of LTSS and did not require people to use the services on an ongoing basis. KFF’s current counts also differ somewhat from KFF’s annual HCBS survey on account of differences in how states report data in surveys versus how they are reflected in the claims. For example, states do not report unduplicated counts of total enrollees across different types of benefits in KFF’s survey data. See methods for more detail.

In 2020, nearly three-quarters (72%) of people who used Medicaid LTSS were exclusively served in home and community-based settings, but this ranged from 45% in Maine to 94% in North Carolina (Figure 2). The larger share of people receiving care in the community as opposed to in an institution reflects initiatives to make home and community-based care more widely available in recent years and to remove what has been referred to as the “institutional bias” in Medicaid. The shift towards HCBS is readily apparent in analyses of Medicaid spending on LTSS: The percentage of LTSS spending that pays for HCBS has increased from only 12% in 1988 to 59% in 2019. While the number of people using Medicaid HCBS exceeds the number who use institutional care nationally, several states still serve fewer than half of people in exclusively home and community-based settings. Over 5% of Medicaid LTSS users in eight states (MN, IN, TN, NJ, IL, CT, KS, and OH) used both institutional care and HCBS. Such people may have transitioned between institutional and community-based settings due to changes in their level of need during the year.

Among the 4.2 million people who used HCBS in 2020, at least 1.9 million used services provided through a state plan such as home health and personal care and at least 1.7 million received services through a waiver (Figure 3). Federal Medicaid statute requires states to cover home health, but the remainder of HCBS are optional. An additional 837,000 people used other HCBS services that were a mix of state plan and waiver services. Among people who used home health, personal care, and “other” HCBS, 0.5 million used more than one type of HCBS. (KFF categorized people using waiver services as only using waiver services, although in some states, people could potentially receive services through a waiver and through the state plan.) In most states, the range of benefits available through a waiver are more comprehensive than those available through the state plan (see Appendix Table), but most states limit the number of people who may use waiver services, often resulting in waiting lists. In a 2022 survey of states HCBS programs, states reported that there were 656,000 people on waiting lists, with people waiting an average of 45 months to receive waiver services.

What Do We Know About Spending for People Who Used Medicaid LTSS in 2020?

Medicaid spending per-person is higher for people who use institutional LTSS and people who use HCBS when compared to those who do not use any LTSS, but spending for people using institutional LTSS is particularly high (Figure 4). In 2020, Medicaid spending—including LTSS and other services such as hospital care and prescription drugs—for the 5.6 million enrollees who used Medicaid LTSS, totaled nearly $217 billion. Per-person spending for these enrollees was $38,769. In comparison, Medicaid spent $4,480 per enrollee who did not use Medicaid LTSS, although that total includes children who comprise 40% of Medicaid enrollees and tend to have much lower spending per person. Medicaid spent an average of $36,275 per person for people who used HCBS and $47,279 per person for people who used institutional LTSS.

People who used Medicaid LTSS comprised 6% of Medicaid enrollment but 37% of federal and state Medicaid spending (Figure 5). The 5% of Medicaid enrollees who used HCBS comprised 26% of Medicaid spending and the 2% of Medicaid enrollees who used institutional LTSS comprised 13% of Medicaid spending. High per-person Medicaid spending among enrollees who use LTSS likely reflects the generally high cost of LTSS and more extensive health needs among such groups that lead to higher use of other health care services and drugs as well.

What Current Policy Questions Could Affect People Who Use Medicaid LTSS?

The COVID-19 pandemic greatly exacerbated shortages of LTSS workers, and many policy questions pertain to expanding the workforce caring for people who use Medicaid LTSS. Recent analysis on the Peterson-KFF Health System Tracker shows that, as of June 2023, the number of workers in LTSS settings was measurably lower than in early 2020. Shortages and high turnover among LTSS workers reflect demanding working conditions and relatively low wages. Workforce shortages have negative effects on the quality of care provided in institutional LTSS settings, and often result in people getting fewer hours or types of HCBS than they need. During the pandemic, states relied on family caregivers to help fill some of those gaps, but many pandemic-era policies will end in November 2023 if they are not transitioned into permanent policies.

The federal government may use its authority to require increased staffing for Medicaid LTSS, but it is not clear what the exact policies will be or how they will be implemented. The Biden Administration is expected to release a proposed rule that would increase nursing facility staffing levels in the near future, but it is unknown what the new staffing levels might be. KFF analysis finds that although nearly all facilities would meet a requirement of 2.5 or fewer HPRD and 85% of facilities would meet a requirement of 3.0 HPRD, but close to half (45%) of all nursing facilities would not meet a 3.5 HPRD requirements, and only 29% would meet an HPRD of 4.0. For HCBS, the Biden Administration recently released a proposed rule aimed at ensuring access to Medicaid services, which has several notable provisions aimed at addressing HCBS workforce challenges. Notably, the states would be required to report payment rates for certain HCBS, to demonstrate that payment rates are “adequate” to provide the level of services in enrollees’ personalized care plans, and to ensure at least 80% of payments are passed through to worker compensation for certain types of HCBS. Higher staffing levels could increase payment rates and spending for LTSS, but it’s unknown who would pay those additional costs.

Although most states have increased payment rates for LTSS, it is unclear where additional funding would come from to further increase payment rates and engage additional staff. In an FY 2022 survey conducted of Medicaid officials in all 50 states and D.C., 44 states implemented Medicaid rate increases in FY 2022 for nursing facilities. Similarly, a 2022 survey of Medicaid HCBS programs found that nearly all states reported experiencing shortages of direct care workers and many reported adopting policies to bolster the HCBS workforce, such as providing recruitment or retention bonuses and increasing provider payment rates. Many of the HCBS initiatives were funded by extra federal funding available through the American Rescue Plan Act, but as that funding expires, states will have to find alternative funding sources if they want to maintain spending levels.

Looking ahead, as the population continues to age, it is likely that more people will need Medicaid LTSS and that workforce challenges will persist. The data on LTSS users provide a rich source of information about who is using LTSS and this data note highlights how many people are currently using LTSS and what types of LTSS they are using.

Key Findings

• As a relatively new class of prescription drugs, initially approved to treat type 2 diabetes, have been gaining attention for their use as effective weight loss drugs, the latest KFF Health Tracking Poll finds that nearly half of adults (45%) say they would generally be interested in taking a safe and effective prescription weight loss drug, including nearly six in ten (59%) of those who are currently trying to lose weight and half (51%) of those who are trying to lose less than 10 pounds. About seven in ten adults say they have heard at least “a little” about this new class of weight loss drugs, which include Ozempic, Wegovy and Mounjaro.
• While there is overall interest in taking a prescription weight loss drug, interest decreases substantially once people are asked if they would take a drug administered as routine injection (23% of all adults would still be interested), if it was not covered by their insurance (16%), if it was not approved by the FDA for weight loss specifically (16%), or if they heard they may gain weight back after stopping use (14%).
• Most adults (80%) say that insurance companies should cover the cost of weight loss drugs for adults who are overweight or obese, while half of adults (53%) say insurance should cover the cost of these drugs for anyone who wants them to lose weight. Half of adults continue to say that health insurance should cover the cost of weight loss drugs, even if it meant that monthly health insurance premiums increased for everyone, including larger shares of Democrats (62%).
• Interest and demand for these new weight loss drugs comes at a time when a majority of the public say they trust pharmaceutical companies to develop new drugs (75%) and provide reliable information about safety and side effects (66%) as well as drug effectiveness (64%) – but far fewer adults (22%) say they trust these pharmaceutical companies to price their products fairly. A large majority of adults (83%), including majorities across partisans, see pharmaceutical profits as a major factor contributing to the cost of prescription drugs.
• Notable shares of adults (28%) report difficulty affording prescription drugs, with another three in ten adults (31%) reporting not taking their medicine as prescribed in the past year due to the cost. Lower income adults are more likely than those with higher household incomes to report experiencing these cost-related prescription drug issues.
• Majorities across partisans say there is not enough regulation over drug pricing, however, just under a year after the passage of the Inflation Reduction Act, few adults in the U.S. are aware of the law’s provisions aimed at reducing the cost of prescription drugs in Medicare. While adults ages 65 and older – the group who will be most affected by the law’s Medicare provisions – are more likely than younger adults to know about some of these aspects of the law, a majority of older adults are still unaware whether these provisions are currently in place. About four in ten (44%) of those ages 65 and older say they are aware of insulin caps for people with Medicare, and about three in ten say they are aware of annual out-of-pocket prescription drug limits for people with Medicare (34%) or the requirement that the federal government negotiate the price of some prescription drugs for people with Medicare (31%), while just 5% say they are aware of penalties for drug companies for increasing prices faster than inflation for people with Medicare.

Public Opinion On A New Class Of Weight Loss Drugs

A new class of prescription drugs, initially developed to treat type 2 diabetes, have been garnering an increasing amount of attention due to their ability to act as highly effective weight loss drugs for overweight or obese adults. This class of drugs includes different medications, such as Ozempic, Wegovy, and Mounjaro.¹  The latest KFF Tracking Poll examines public interest and awareness of these drugs as well as how views change once people hear more information about the accessibility and administration of the medications.

Seven in ten adults say they have heard at least “a little” about a new class of drugs being used for weight loss, such as Ozempic, Wegovy, and Mounjaro, with about one in five (19%) saying they have heard “a lot” about these drugs.

Awareness of the new weight loss drugs is high among all groups, but older adults are some of the most aware with at least eight in ten adults ages 65 and older (79%) saying they have heard about them. Three in four adults (76%) who have been told by a doctor in the past five years that they are overweight or obese are also aware of this new class of drugs being used for weight loss. Awareness is also high among adults who are currently trying to lose weight, with three in four (74%) saying they have heard about these drugs.

While most adults report having heard at least “a little” about this new class of weight loss drugs, very few report having ever taken any prescription drug to lose weight, with even fewer who report currently taking a prescription drug for weight loss. Just 4% of adults say they are currently taking a prescription drug to lose weight and one in ten say they have previously taken prescription drugs for weight loss but are not currently using them, leaving about nine in ten adults (87%) who say they have never taken any prescription weight loss drugs.

Overall, about six in ten adults (61%) say they are currently trying to lose weight, including 28% who are trying to lose more than 20 pounds. About four in ten (39%) adults say a doctor or other health care provider has told them that they are overweight or obese²  in the past five years. Prior use of weight loss drugs is also more common among these groups.

One in ten of those who are currently trying to lose more than 20 pounds and a similar share of adults who have been told by a doctor in the past five years that they are obese or overweight say they are currently taking medications for weight loss. An additional one in six among each of these groups say they have taken medications for weight loss in the past.

Women are about twice as likely as men to say they have ever used any prescription drug to lose weight (18% v. 8%) and are also more likely to say they are currently using these drugs to lose weight (5% v. 2%). Notably, women are also more likely than men to say that a doctor or other health care provider told them they were overweight or obese in the past five years (47% v. 32%).

Nearly half of adults (45%) say they would be interested in taking a prescription drug to lose weight if they heard that it was safe and effective, including about one in five (18%) who say they are “very interested.” Women are significantly more likely than men to say they would be interested in taking a prescription drug for weight loss (51% v. 38%). About four in ten Black adults (41%), nearly half of White adults (45%), and just over half of Hispanic adults (55%) say they would be interested in taking a prescription weight loss drug. While similar shares of Black adults, Hispanic adults and White adults report being told by a doctor or health care provider in the past five years that they are overweight or obese, KFF’s analysis of Centers for Disease Control (CDC) data shows that Black and Hispanic adults in the U.S. have a higher rate of obesity than White adults. For additional information on obesity rates and racial disparities, see KFF’s policy watch: What are the Implications of New Anti-Obesity Drugs for Racial Disparities?

The share who say they are interested in taking prescription drugs for weight loss increases to two-thirds (67%) among those who have been told by a doctor or health care provider that they are overweight or obese in the past five years. In addition, about six in ten (59%) adults who say they are currently trying to lose weight say they would be interested in taking a weight loss drug.

Interest in taking a prescription drug for weight loss is even more common among those who say they are trying to lose relatively larger amounts of weight, however, notable shares of those who are trying to lose 10 pounds or less also say they would be interested in taking a safe, effective prescription drug for weight loss. About seven in ten (68%) adults who say they are currently trying to lose 20 pounds or more say they would be interested in taking a prescription drug for weight loss if they heard it was safe and effective, compared to about half of adults who are trying to lose 10 to 20 pounds (50%) or less than 10 pounds (51%). But interest for taking such medications isn’t limited to those currently trying to lose weight; a quarter (23%) of those who say they are not currently trying to lose weight say they would be interested in taking a drug to lose weight if they heard it was safe and effective.

While notable shares of adults who say they are trying to lose relatively small amounts of weight say they would be interested in taking a prescription drug for weight loss if they heard it was safe and effective, it is worth noting that among the relatively new class of drugs being used for weight loss, Wegovy, which is approved by the FDA for weight loss, is intended for chronic weight management in adults who are obese, or adults who are overweight and have one weight-related condition, such as type 2 diabetes.

While about half of adults express interest in taking safe, effective prescription drugs for weight loss, some people are no longer interested after hearing additional information about these drugs. Similar to the share of adults who are interested in taking a drug for weight loss if it was safe and effective, nearly half of all adults (44%) continue to be either “very” or “somewhat” interested in taking medication like this if it could be taken it as a pill.³   But interest drops more than twenty percentage points when adults are asked if they would be interested if they had to administer it themselves as a weekly injection (23%), if it was not covered by their insurance (16%), or if it was not approved by the FDA for weight loss but was approved for another use (16%). Interest in taking a medication for weight loss drops to 14% when people hear they may gain weight back after stopping use.⁴ 

Eight in ten adults say they think health insurance should cover the cost of prescription weight loss drugs for adults who have been diagnosed as overweight or obese, while about half (53%) of adults say health insurance should cover the cost of these drugs for anyone who wants to take them to lose weight. Half of adults continue to say they think health insurance should still cover these costs even if they heard that it could generally increase monthly health insurance premiums for everyone.

While majorities across partisans say that health insurance should cover the cost of prescription weight loss drugs for either anyone who wants them or for adults diagnosed as overweight or obese, larger shares of Democrats say this (88%) compared to independents (81%) and Republicans (77%). Additionally, about six in ten Democrats (62%) say insurance should still cover the cost of weight loss drugs even at the expense of higher premiums for everyone compared to about half of independents (48%) and four in ten Republicans (39%).

While large majorities across age groups say health insurance should cover the cost of prescription weight loss drugs for either anyone who wants them or for adults diagnosed as overweight or obese, people under the age of 65 are more likely than those ages 65 and older to say they still think insurance should cover the cost of prescription weight loss drugs even if they heard that it might increase insurance premiums for everyone (53% v. 39%).

Views On Pharmaceutical Companies And Concerns Over Prescription Drug Pricing

Alongside public interest in new weight loss drugs and notable shares of adults saying they think health insurance should cover the cost of these drugs – even at the expense of increasing monthly premiums for everyone – most adults report a lack of trust in pharmaceutical companies to price their drugs fairly and say there is not enough regulation when it comes to prescription drug costs. Notable shares also experienced cost-related issues with prescription drugs in the past year, with three in ten adults reporting not taking their prescription medicine as prescribed due to the cost. Most adults, however, are trusting of drug companies when it comes developing new drugs and communicating reliable information about the safety and effectiveness of their drugs.

Three-quarters (75%) of adults say they trust pharmaceutical companies either “a lot” or “somewhat” to develop new, effective drugs, and just over six in ten say they trust drug companies to offer reliable information about the side effects and safety of their drugs (66%) or to offer reliable information about how well their drugs work (64%). Fewer, or about half (48%), of all adults say they trust pharmaceutical companies to inform the public quickly when they learn of a safety concern with their drugs. Adults are least trusting when it comes to drug pricing, with one in five (22%) saying they trust drug companies “a lot” or “somewhat” to price their products fairly.

Most adults, including majorities across partisans, cite profits made by pharmaceutical companies as a “major factor” contributing to the price of prescription drugs. About eight in ten adults (83%) say profits made by pharmaceutical companies are a “major factor” contributing to the price of prescription drugs, compared to fewer who say the cost of research and development (54%) or the cost of marketing and advertising (45%) are major contributing factors. Additionally, majorities across partisans cite profits made by pharmaceutical companies as the main factor contributing prescription drug prices, including nine in ten Republicans (89%) and similar shares of Democrats (84%) and independents (78%).

While many adults report a lack of trust in pharmaceutical companies to price their products fairly, notable shares of adults also report experiencing problems affording prescription drugs, with three in ten (28%) saying it is either “somewhat” or “very difficult” to afford prescription drugs, including larger shares of those with annual household incomes of less $40,000 a year (40%).

Another three in ten adults (31%) say they haven’t taken their medicine as prescribed due to cost. This includes one in five adults who say they have not filled a prescription for a medicine due to the cost (21%) or taken an over-the-counter drug instead of getting a prescription filled because of the cost, and about one in ten (12%) who say they have cut pills in half or skipped doses of medicine because of the cost in the past year.

Lower income adults are more likely than those with higher incomes to experience these cost-related prescription drug issues. Just under four in ten (37%) of those with annual household incomes of less than $40,000 say they haven’t taken their medicine as prescribed due to the cost in the past year compared to three in ten (30%) of those with annual incomes between $40,000 and less than $90,000 and a quarter (24%) of those with incomes of $90,000 or more.

Most adults say there should be more regulation when it comes to prescription drug costs. Three quarters (73%) of adults say there is not enough government regulation when it comes to limiting the price of prescription drugs, with just 13% saying there is “about the right amount” of regulation in this area. About half (47%) of adults say there is not as much government regulation as there should be when it comes to making sure prescription drugs are safe for people to use, while four in ten say there is the right amount of government regulation in this area. The share of adults currently saying there is not as much regulation as there should be in each of these areas has increased by about 10 percentage points since 2021.

Majorities of adults across partisans agree that there is not enough regulation over prescription drug prices, with eight in ten Democrats (82%) and just over two-thirds of Republicans (68%) and independents (67%) saying there is not as much regulation as there should be when it comes to limiting the price of prescription drugs. Similar to increases among the total population, the shares of Democrats and Republicans saying there is not enough regulation in limiting the price of prescription drugs has increased by about ten percentage points since 2021.

Half (49%) of adults ages 18 to 64 say there is not as much regulation as there should be when it comes to making sure prescription drugs are safe for people to use, while two in five (40%) of those ages 65 and older say there is not enough regulation in this area. When it comes to regulation over prescription drug prices, similar shares of those under the age of 65 (73%) and those 65 and older (72%) say there is not as much regulation as there should be.

The Public’s Knowledge of the Inflation Reduction Act

Even as many adults, regardless of partisanship or age, say there is not enough regulation over limiting prescription drug prices, few adults are aware of new prescription drug regulations included in the Inflation Reduction Act (IRA). Signed into law in August of 2022 by President Joe Biden, the IRA contains several provisions related to lowering prescription drug costs for people with Medicare. Namely, the law caps the cost of insulin for people with Medicare at $35 a month, requires the federal government to negotiate the price of some prescription drugs for people with Medicare, places an annual limit on out-of-pocket prescription drug costs for people with Medicare, and penalizes drug companies for increasing prices faster than the rate of inflation for people with Medicare. For more information, see KFF’s issue brief on the IRA’s prescription drug provisions.

Nearly a year after being signed into law, few adults are aware of the IRA’s provisions related to prescription drug costs in Medicare. A quarter of adults say they are aware there are federal laws in place that cap monthly insulin costs at $35 for people with Medicare (25%), that require the federal government to negotiate the price of some prescription drugs for people with Medicare (25%), or that place a limit on annual out-of-pocket drug costs for people with Medicare (24%). Even fewer adults are aware there is a law in place that penalizes drug companies for increasing prices faster than the rate of inflation for people with Medicare (10%).

Adults ages 65 and older – most of whom are covered by Medicare– are more likely than younger adults to know these regulations are currently in place. But still, fewer than half of older adults are aware of these provisions. Twice the share of older adults (those ages 65 and older) are aware of the cap on monthly insulin costs for people with Medicare (44%) compared to those under the age of 65 (20%). Older adults are also more likely than younger adults to know there is a law that sets an annual limit on out-of-pocket drug costs for people with Medicare (34% v. 21%) and government negotiation requirements for some prescription drugs for people with Medicare (31% v. 23%). However, few adults in either age group are aware there is a law in place that penalizes drug companies for increasing prices faster than the rate of inflation (5% of those ages 65 and older and 11% of those under age 65).

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at KFF. The survey was conducted July 11-19, 2023, online and by telephone among a nationally representative sample of 1,327 U.S. adults in English (1,246) and in Spanish (81). The sample includes 1,043 adults reached through the SSRS Opinion Panel either online or over the phone (n=46 in Spanish). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails. 1,022 panel members completed the survey online and panel members who do not use the internet were reached by phone (21).

Another 284 (n=35 in Spanish) interviews were conducted from a random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Respondents in the phone samples received a $15 incentive via a check received by mail, and web respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card).

The online questionnaire included two questions designed to establish that respondents were paying attention. Cases that failed both attention check questions, those with over 30% item non-response, and cases with a length less than one quarter of the mean length by mode were flagged and reviewed. Cases were removed from the data if they failed two or more of these quality checks. Based on this criterion, no cases were removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2022 Current Population Survey (CPS). Weighting parameters included sex, age, education, race/ethnicity, region, and education. The sample was weighted to match patterns of civic engagement from the September 2019 Volunteering and Civic Life Supplement data from the CPS and to match frequency of internet use from the National Public Opinion Reference Survey (NPORS) for Pew Research Center.  Finally, the sample was weighted to match patterns of political party identification based on a parameter derived from recent ABS polls conducted by SSRS polls. The weights take into account differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

1. Both Ozempic (semaglutide) and Mounjaro (tirzepatide) have been approved by the Food and Drug Administration (FDA) for treatment of type 2 diabetes; Wegovy (semaglutide) has been approved by the FDA for chronic weight management in adults who are obese or are overweight with at least one weight-related condition. These medications, all known as GLP-1 agonists, are typically administered as a routine injection. Currently, these prescription drugs come with a price tag for many adults, as insurance coverage is limited, out-of-pocket costs remain high and current US law prohibits Medicare from covering drugs used for weight loss. The most common side effects of these drugs include mild to moderate gastrointestinal issues, such as nausea and vomiting. ↩︎
2. This is based upon adults who said a doctor or other health care provider has told them they are overweight or obese in the past five years and may differ from clinical estimates of obesity rates. For additional information on obesity rates in the U.S., see KFF’s State Health Facts on obesity. ↩︎
3. Recent clinical trials have been studying the efficacy of these drugs when taken in pill form. ↩︎
4. A recent study showed that participants regained most of their lost weight back after discontinuing semaglutide (the active ingredient in Ozempic and Wegovy) ↩︎

Medicare and Medicaid provide health coverage to 12.5 million individuals who are enrolled in both programs, known as “dual-eligible individuals.” Medicare is their primary source of health insurance coverage, and Medicaid, jointly funded by federal and state governments, provides supplemental coverage. Under the broad umbrella of Medicare coverage, dual-eligible individuals can be covered under a variety of different arrangements, including traditional Medicare, Medicare Advantage plans that are available to all Medicare beneficiaries, and plans that are designed specifically for this population (referred to here as “dual-eligible plans”).

Together, Medicare and Medicaid cover a range of services and financial supports to help meet the diverse needs of the dual-eligible population, which is more racially and ethnically diverse, and more likely to be in poor health than Medicare beneficiaries without Medicaid. At the same time, there are ongoing concerns about a lack of integration of services across the two programs that may contribute to fragmentation of care, poor outcomes, and high costs. In response to these concerns, federal and state lawmakers have been working to develop, test and implement a variety of coverage and financing options to improve coordination of care for this population.

To inform consideration of these coverage and financing options, including what they might mean for how dual-eligible individuals get their Medicare and Medicaid benefits, and who would be most affected, this brief presents national and state-level sources of Medicare coverage for dual-eligible individuals, by demographic characteristics, based on the 2020 Medicare Beneficiary Summary File (See Methods for details and Appendix Table 1).

Key takeaways:

• Just over half (51%) of dual-eligible individuals received their Medicare benefits through traditional Medicare in 2020, while the remaining 49% were enrolled in Medicare Advantage plans (Figure 1).
• Three in 10 (30%) dual-eligible individuals were enrolled in a dual-eligible plan, most of whom (24%) were in coordination-only dual eligible special needs plans (D-SNPs). Coordination-only D-SNPs are designed for dual-eligible individuals and are required to coordinate with state Medicaid programs, with some variation in the specific requirements across states.
• Enrollment of dual-eligible individuals in traditional Medicare ranged from less than 30% in Hawaii and Puerto Rico to 70% or over in 11 states (Alaska, Delaware, Maryland, Montana, North Dakota, New Hampshire, Oklahoma, South Dakota, Vermont, West Virginia, and Wyoming).
• Among dual-eligible individuals, Medicare Advantage enrollment rates were higher among beneficiaries who were age 65 and older than those under age 65 (53% vs 41%) and among beneficiaries who were Black (54%), Hispanic (65%), and Asian/Pacific Islander (48%) than non-Hispanic White beneficiaries (41%).

Overview of Medicare Coverage Options for Dual-Eligible Individuals

Like all Medicare beneficiaries, dual-eligible individuals may choose to receive their Medicare benefits through traditional Medicare or a Medicare Advantage plan. This decision may have implications for how dual-eligible individuals receive their Medicaid benefits and the degree to which that coverage is coordinated with Medicare. State Medicaid programs cover benefits that Medicare does not cover, such as long-term services and supports and non-emergency transportation, as well as a broader set of behavioral health services through Medicaid fee-for-service or Medicaid managed care. Most (73%) dual-eligible individuals are eligible for the full range of Medicaid benefits not otherwise covered by Medicare and are referred to as “full-benefit” dual-eligible individuals. Medicaid also provides most full-benefit dual-eligible individuals premium and in many cases, cost-sharing assistance through the Medicare Savings Program. “Partial-benefit” dual-eligible individuals are not eligible for full Medicaid benefits but are eligible for assistance with Medicare premiums and, in many cases, cost sharing, also through the Medicare Savings Programs.

The various Medicare coverage options for dual-eligible individuals are summarized below and in Appendix Table 1.

Traditional Medicare

In traditional Medicare, beneficiaries can obtain care from any provider that participates in Medicare. The payment and delivery of care in traditional Medicare has evolved over the last several decades, with payment including a mix of fee-for-service, bundled, and prospective payments, as well as value-based payment models, such as Accountable Care Organizations (ACOs). ACOs are a group of doctors, hospitals and providers that form partnerships to be collectively responsible for the care coordination of their patients.

Medicare Advantage

Medicare Advantage plans receive a payment from the federal government to deliver Medicare Part A and Part B benefits, and, typically, Part D drug coverage. Medicare Advantage plans often provide some coverage of supplemental benefits, such as vision and dental. These plans are permitted to limit provider networks and may require prior authorization for certain services or referrals for certain types of providers. In this brief, all private plans are referred to as Medicare Advantage plans, including cost contract plans, health care prepayment plans, Program of All-Inclusive Care for the Elderly, and Medicare-Medicaid plans. Medicare Advantage plans have been categorized into dual-eligible plans and non-dual-eligible plans (described below).

Dual-eligible plans

In this brief, dual-eligible plans are defined as private plans or programs that are designed for people who are dually enrolled in Medicare and Medicaid and, to varying degrees, coordinate benefits across the two programs. Dual-eligible individuals are not required to enroll in a dual-eligible plan, although in some states, Medicare-Medicaid plans (MMPs) and fully integrated dual-eligible (FIDE) SNPs have the option to passively enroll dual-eligible individuals, which means individuals would need to opt-out if they prefer a different Medicare coverage arrangement. Financing of dual-eligible plans also varies across plan types, and often within plan types depending on the degree of coordination in coverage and benefits.

In this analysis, dual-eligible plans include:

• Dual eligible special needs plans (D-SNPs) are a type of Medicare Advantage plan that provide Medicare coverage and may coordinate or cover Medicaid benefits depending on the type of D-SNP. D-SNPs have contracts with the federal government to provide coverage to Medicare beneficiaries and receive a capitated payment to cover the cost of all Medicare-covered services and supplemental benefits included in the plan. When supplemental benefits duplicate Medicaid-covered benefits, the Medicare payment covers these costs. D-SNPs are required by Medicare to have contracts with Medicaid programs in the states in which they operate and must meet minimum requirements, including those related to coordinating the delivery of benefits with the Medicaid program. States have the option to limit enrollment in these plans to full-benefit dual-eligible individuals. There are three types of D-SNPs:
  • Coordination-only D-SNPs must meet the minimum federal requirements but provide varying levels of coordination, depending on state requirements. These D-SNPs provide Medicare-covered services and in most cases supplemental benefits, and the state Medicaid agency or a Medicaid managed care plan provides Medicaid-covered services. Most D-SNPs fall into this category.
  • Fully Integrated Dual-Eligible (FIDE) SNPs provide Medicare- and included Medicaid-covered services through a single managed care organization. The same organization that offers the FIDE SNP must also offer a Medicaid managed care plan for any Medicaid benefits not included in the FIDE SNP. In some cases, certain Medicaid benefits may be provided by the state or by a different health plan. FIDE SNPs are paid by Medicare for Medicare-covered services and included supplemental benefits, and by Medicaid for Medicaid-covered services. It is possible for people to enroll in a FIDE SNP but not the companion Medicaid plan or vice versa. Starting in 2025, FIDE SNPs may only enroll full-benefit dual-eligible individuals if they are enrolled in both the FIDE SNP and the Medicaid plan sponsored by the same organization.
  • Highly Integrated Dual-Eligible (HIDE) SNPs must meet the requirements of coordination-only D-SNPs and must also have a Medicaid plan operating in the same counties as the D-SNP. The parent organization provides both Medicare and Medicaid services, but there is no requirement that the same people enroll in both plans. HIDE SNPs were not available until 2021 and are not included in this analysis.
• Medicare-Medicaid Plans (MMPs) were established as a demonstration under the Financial Alignment Initiative where a single health plan provides all Medicare- and Medicaid-covered benefits. Enrollment in MMPs is limited to full-benefit dual-eligible individuals. Recent regulations require that all states end their demonstration programs of the MMP model by the end of 2025 and transition remaining plans to HIDE or FIDE SNPs.
• Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive medical and social services to individuals who: (1) are 55 years of age or older, (2) need a nursing home level of care but can live safely in the community, and (3) live in a PACE organization service area. Most people in PACE are dual-eligible individuals. PACE was made a permanent part of the Medicare and Medicaid programs by the Balanced Budget Act of 1997.

Non-dual-eligible plans

Non-dual-eligible plans are other Medicare Advantage and private plans that may enroll dual-eligible individuals but do not coordinate Medicare and Medicaid benefits. These include individual Medicare Advantage plans that are generally available for enrollment to all people with Medicare, group plans sponsored by employers and unions, and other SNPs for Medicare beneficiaries with specialized health needs, including institutional special needs plans (I-SNPs) and chronic condition special needs plans (C-SNPs).

What share of dual-eligible individuals were enrolled in traditional Medicare and Medicare Advantage plans?

Just over half (51%) of all dual-eligible individuals were in traditional Medicare and 49% were enrolled in Medicare Advantage plans in 2020.

A smaller share of dual-eligible individuals were enrolled in traditional Medicare than the share of Medicare beneficiaries without Medicaid coverage in traditional Medicare (51% vs. 57%, respectively) (Figure 2 and Appendix Table 2).

Of the 10.9 million dual-eligible individuals enrolled in Medicare Part A and B in 2020, 5.6 million were in traditional Medicare and 5.3 million were enrolled in Medicare Advantage plans. However, among 5.3 million dual-eligible individuals enrolled in a Medicare Advantage plan, the majority (61%) were enrolled in a dual-eligible plan, and the remaining 39% were in a non-dual-eligible plan (data not shown).

Among all dual-eligible individuals, 3 in 10 (30%) were enrolled in dual-eligible plans (Figure 2). Enrollment in dual-eligible plans consisted primarily of enrollment in coordination-only D-SNPs (24%), followed by MMPs (3%), FIDE SNPs (3%), and PACE (0.4%). Higher enrollment in coordination-only D-SNPs than other dual-eligible plan types is likely driven by higher plan availability, since the other types of plans were only available in a limited number of states, and often in a subset of counties in 2020 (e.g., FIDE SNPs, 11 states; MMPs, 9 states; and PACE, 31 states).

About 1 in 5 (19%) dual-eligible individuals were enrolled in a Medicare Advantage plan that was not designed for people with both Medicare and Medicaid, primarily individual Medicare Advantage plans available to all Medicare beneficiaries (17% of all dual-eligible individuals). Another 2% were in an I-SNP or C-SNP. In 2020, most people enrolled in I-SNPs (91%) were dual-eligible individuals, while just over one-quarter (26%) of enrollees in C-SNPs were dual-eligible individuals.

In 37 states and the District of Columbia, at least 50% of dual-eligible individuals received their Medicare coverage through traditional Medicare in 2020, including 11 states where 70% or more of dual-eligible individuals were in traditional Medicare (Figure 3). The share of dual-eligible individuals in traditional Medicare ranged from a high of 99% in Alaska to a low of 0.3% in Puerto Rico. The share of dual-eligible individuals in traditional Medicare across states was generally similar to the share of Medicare beneficiaries without Medicaid in traditional Medicare, except in 6 states (Arizona, Florida, Hawaii, Rhode Island, South Carolina, and Tennessee) and Puerto Rico (Appendix Table 2). For example, in Arizona, 30% of dual-eligible individuals were in traditional Medicare versus 59% of Medicare beneficiaries without Medicaid.

In five states (Arizona, Florida, Hawaii, Rhode Island, and Tennessee) and Puerto Rico, more than 40% of dual-eligible individuals were enrolled in a dual-eligible plan – higher than the national share of dual-eligible individuals in a dual-eligible plan (30%). In four of these states, the relatively high enrollment in dual-eligible plans was driven by enrollment in coordination-only D-SNPs, including Arizona (39%), Florida (43%), Hawaii (57%) and Tennessee (42%), while in Rhode Island, the enrollment in dual-eligible plans was highest in MMPs (33%). In contrast, in 4 states (Maryland, Montana, North Dakota and Oklahoma), less than 10% of dual-eligible individuals were enrolled in a dual-eligible plan (Figure 3, Appendix Table 3).

The share of dual-eligible individuals in traditional Medicare and Medicare Advantage plans differed across subgroups of beneficiaries by race, age, and area of residence.

A larger share of Black (54%), Hispanic (65%) and Asian/Pacific Islander (48%) dual-eligible individuals were enrolled in Medicare Advantage plans than non-Hispanic White (41%) and American Indian/Alaska Native (25%) dual-eligible individuals. Lower enrollment in coordination-only D-SNPs among non-Hispanic White individuals (16%) compared to Black (28%), Hispanic (37%) or Asian/Pacific Islander (24%) beneficiaries explains lower overall enrollment in Medicare Advantage plans among non-Hispanic White dual-eligible individuals.

A larger share of dual-eligible individuals under age 65 received their Medicare coverage through traditional Medicare than dual-eligible individuals age 65 or older (59% vs 47%) (Figure 5). Higher enrollment in Medicare Advantage plans among dual-eligible beneficiaries age 65 or older compared to those under 65 (53% vs. 41%) is almost entirely accounted for by higher enrollment in individual Medicare Advantage plans (20% vs 13%).

Two-thirds (67%) of dual-eligible individuals living in rural areas received their Medicare coverage through traditional Medicare compared to less than half (48%) of dual-eligible individuals living in metropolitan areas. Traditional Medicare was also the more common source of Medicare coverage for dual-eligible individuals living in a micropolitan area, where 62% were in traditional Medicare. In addition, a larger share of dual-eligible individuals in metropolitan areas were enrolled in coordination-only D-SNPs (25%), FIDE SNPs (3%) and MMPs (4%) than dual-eligible individuals in micropolitan areas (18%, 1% and 1%, respectively) and rural areas (14%, 1% and 0.4%, respectively) (Figure 4).

A larger share of full-benefit dual-eligible individuals were in traditional Medicare than partial-benefit dual-eligible individuals.

Among dual-eligible individuals who received full benefits in 2020, nearly 6 in 10 (55%) were enrolled in traditional Medicare, while 45% were enrolled in Medicare Advantage plans. For dual-eligible individuals receiving partial benefits, the pattern was reversed, with 58% enrolled in Medicare Advantage plans and 42% in traditional Medicare (Figure 5).

Three in 10 (33%) full-benefit dual-eligible individuals were enrolled in dual-eligible plans, compared to approximately 2 in 10 (23%) partial-benefit dual-eligible individuals. Among full-benefit dual-eligible individuals, enrollment in dual-eligible plans was largely comprised of enrollment in coordination-only D-SNPs (24% of full-benefit dual-eligible individuals), followed by MMPs (5%), FIDE SNPs (4%), and PACE (1%). All partial-benefit dual-eligible individuals in dual-eligible plans were in coordination-only D-SNPs, largely due to enrollment restrictions in other dual-eligible plan types.

A smaller share of full-benefit dual-eligible individuals were enrolled in non-dual-eligible Medicare Advantage plans than partial-benefit dual-eligible individuals (12% vs 35%). Among dual-eligible individuals receiving full benefits, 10% were in individual Medicare Advantage plans, while among those receiving partial benefits, 34% were in individual Medicare Advantage plans.

Consistent with the overall enrollment patterns for full-benefit dual-eligible individuals, in most states (39) and the District of Columbia, more than half of full-benefit dual-eligible individuals were in traditional Medicare. In contrast, in half of states (26), more than half of partial-benefit dual-eligible individuals were enrolled in Medicare Advantage plans (Appendix Table 4).

Discussion

In 2020, one third (30%) of dual-eligible individuals were enrolled in a Medicare Advantage plan designed for people with both Medicare and Medicaid, 19% were in another Medicare Advantage plan, and just over half (51%) received their Medicare coverage through traditional Medicare. The source of Medicare coverage for dual-eligible individuals varied by state and by beneficiary characteristics.

Dual-eligible individuals have lower incomes, are more racially and ethnically diverse, and often face greater mental and physical health challenges than the general Medicare population, which can make navigating the health care system and health care coverage challenging for this population. Separate eligibility requirements, benefits, and rules for Medicare and Medicaid may further contribute to what has been described as a “fragmented and disjointed system of care for dual eligibles.”

To address concerns about fragmented care and high costs, some policymakers have proposed to expand the role of Medicare Advantage plans that are designed for dual-eligible individuals (or a subset of these plans). Existing Medicare coverage arrangements for dual-eligible individuals vary in the degree of care coordination and integration of financing between Medicare and Medicaid. Some coverage options may offer a greater degree of coordination and financing (such as FIDE D-SNPs) than others. Plans with generally higher degrees of integration tend to have relatively low enrollment nationwide compared with the more common coverage options, in part because they are not widely available.

Proposals that would require dual-eligible individuals to be covered under a Medicare Advantage plan designed for this population would mean a transition from one source of Medicare coverage to another, potentially disrupting care arrangements between patients and providers depending on network restrictions, for the large share of dual-eligible individuals who are covered under traditional Medicare – a group that is disproportionately non-Hispanic White, under the age of 65 with permanent disabilities, living in rural areas, and living in states where enrollment in dual-eligible plans is currently relatively low.

Higher enrollment among dual-eligible individuals in Medicare Advantage plans designed for this population could potentially address fragmentation challenges between Medicare and Medicaid, though based on current evidence, it is not clear these plans always improve the coordination of care. In addition, it is not clear how such changes would affect expenditures under both programs. Assessing the potential effects of various coverage arrangements on the experiences of dual-eligible individuals, and on Medicare and Medicaid spending is beyond the scope of this analysis but would inform consideration of policy proposals that aim to improve coverage and care for this high-need population.