How Does Use of Medicaid Wraparound Services by Dual-Eligible Individuals Vary by Service, State, and Enrollees’ Demographics?

Data: Monthly enrollment and eligibility information come from the 2019 T-MSIS Research Identifiable Demographic-Eligibility Files and service use come from the 2019 T-MSIS other services (OT) and long-term (LT) claims files. Data from the 50 states and DC are included in this analysis.  The District of Columbia is considered a state for the purposes of this report, but the U.S. territories are excluded on account of differences in the way Medicaid operates in the territories.

Definition of Full-Benefit Dual-Eligible Individuals: Full-benefit dual-eligible individuals include anyone with one or more months of Medicare coverage defined as DUAL_ELGBL_CD_LTST values of 01, 02, 03, 04, 05, 06, 08; and 10 or more months of full Medicaid defined as RSTRCTD_BNFTS_CD_LTST values of 1,A,D,4,5,7.

Definition of Medicaid Enrollees Without Medicaid coverage: Full benefit Medicaid enrollees include anyone with 10 or more months of full Medicaid defined as RSTRCTD_BNFTS_CD  values of 1,A,D,4,5,7; and eligibility for Medicaid based on age 65 or over, blindness, or disability , which includes ELGBLTY_GRP_CD_LTST values of 11, 12, 13, 15-26, 37-60 or if age is greater than 64.

Medicaid enrollees are categorized as follows:

• Under age 65 or ages 65 and older using the Age variable in years;
• Male or female using the SEX_CD variable; and
• Into race and ethnicity groups using the RACE_ETHNCTY_CD from the 29 states that reported “low/medium concern” data quality levels with their race and ethnicity data in 2019. For more information, see DQ Atlas.  Data for those 29 states represent 66% of all full-benefit dual-eligible individuals in the US. The 29 states include: AK, CA, DE, FL, GA, ID, IL, IN, KY, ME, MI, MN, MS, NC, ND, NE, NH, NJ, NM, NV, OH, OK, PA, SD, TX, VA, VT, WA, WI.  Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Data are not shown for people reporting “Unknown” or “Multiracial” racial/ethnic groups which amounted to 489k and 6k dual-eligible individuals, respectively.

Use of LTSS: Medicaid enrollees who use LTSS are identified using the methods described in the issue brief “How Many People Use Medicaid Long-Term Services and Supports and How Much Does Medicaid Spend on Those People?” Methods box.

Use of other wraparound services: Medicaid enrollees who use each service include anyone with one or more fee-for-service claim or managed care encounter for each service type. The specific codes used include the following.

• NEMT services were identified as records with HCPC codes A0080, A0090, A0100, A0110, A0120, A0130, A0140,  A0160, A0170, A0180, A0190, A0200, A0210, S0209,  S0215,  T2001, T2002, T2003,  T2004,  T2005,  T2007,  Z2713,  W7274, W7275, W7276, M0372, M0419, M0373, M0374, M0418, M0420 as described in MACPAC Mandated Report on Non-emergency Medical Transportation.
• Vision services include eye exams with CPT/HCPC codes 92002, 92004, 92012, 92014 provided by any provider type and evaluation and management codes 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 if the procedure provided by an ophthalmologist, optometrist and optician using provider type codes 41, 18, 96 or related provider taxonomy codes; eye glasses with procedure codes V2020, V2025, V2100, V2101, V2102, V2103, V2104, V2105, V2106, V2107, V2108, V2109, V2110, V2111, V2112, V2113, V2114, V2115, V2118, V2121, V2199, V2200, V2201, V2202, V2203, V2204, V2205, V2206, V2207, V2208, V2209, V2210, V2211, V2212, V2213, V2214, V2215, V2218, V2219, V2220, V2221, V2299, V2300, V2301, V2302, V2303, V2304, V2305, V2306, V2307, V2410, V2430, V2499; contact lenses with CPT/procedure codes 92310, 92325, 92326, 92071, 92072, V2510, V2511, V2512, V2513, V2520, V2521, V2522, V2523, V2531, V2599; and low vision aids with procedure codes V2600, V2610, V2615, Z460.
• This methodology uses the CDC’s Vision and Eye Health Surveillance System classifications for Eye exams and/or glasses/contacts. Any treatment, imaging, diagnostic, or screening services were excluded to avoid overlap with Medicare covered services.
• Dental services include any claims with a dental-related procedure code (D0100-D9999) including diagnostic, preventive, restorative, endodontics, periodontics, implant services and prosthodontics, oral and maxillofacial surgery, orthodontics and adjustive general service as described by the American Dental Association.

The analysis presents data from 2019 data, which are expected to be more representative of non-pandemic utilization trends than data from 2020, the most recent year of data available when the analysis was conducted. Use of many health care and wraparound services declined during the pandemic as outpatient and elective services were cancelled, delayed, or avoided among all people. Deferrals and avoidance of care also affected the use of Medicaid wraparound services (Appendix Figure 3).

The most significant limitations of this analysis stem from the fact that the data do not account for the use of Medicare services or type of enrollment in Medicare. Specifically, the analysis does not distinguish between dual-eligible individuals based on whether they were enrolled in different types of Medicare Advantage (MA) plans, which usually cover supplemental benefits. The analysis is also unable to identify whether dual-eligible individuals are using Medicare-covered services, which in some cases may overlap with Medicaid supplemental benefits.

This analysis does not examine if rates of use for wraparound services are associated with different rates of need (medical condition or functional status) or different rates of access to services. This analysis includes the share of dual-eligible individuals who use a particular wraparound service among all dual-eligible individuals, but among those who do not use the services, it is unknown whether the lack of use reflects lack of need or lack of access.