What Do People with Medicare Think About the Role of Marketing, Shopping for Medicare Options, and Their Coverage?

Introduction

The Medicare plan landscape has transformed markedly in recent years, with more than half of all Medicare beneficiaries enrolled in Medicare Advantage plans. When Medicare beneficiaries first enroll in Medicare and during the annual open enrollment period, they can choose traditional Medicare or enroll in a Medicare Advantage plan. If Medicare beneficiaries select traditional Medicare, they may also need to purchase a stand-alone Part D prescription drug plan (PDP), and potentially a supplemental Medigap plan, which fully or partially covers Part A and Part B cost-sharing requirements. In lieu of traditional Medicare, beneficiaries can get coverage through private Medicare Advantage plans, which are mainly HMOs and PPOs, that provide all Medicare Part A and B benefits, often for no additional premium for plans open for general enrollment (other than the Part B premium), typically include Part D drug coverage, and may cover other benefits such as dental, vision, and hearing. Some people with Medicare may otherwise receive supplemental coverage through an employer retiree health plan or Medicaid, which may supplement either traditional Medicare or a Medicare Advantage plan.

Dozens of private Medicare Advantage and Part D drug plans are available to people on Medicare. With a large number of plans and coverage options to review, beneficiaries have a myriad of choices to make when they enroll in the Medicare program, particularly as there may be tradeoffs for each of these decisions. For example, Medicare Advantage plans typically have lower premiums compared to traditional Medicare plus a Medigap policy and have extra benefits that traditional Medicare does not cover, such as dental, vision, and hearing. However, Medicare Advantage plans have limited provider networks and apply cost management tools such as prior authorization, which traditional Medicare does not.

Both people in Medicare Advantage and traditional Medicare also make choices about their prescription drug coverage, which can vary across numerous domains, including premiums, cost sharing, formularies, and pharmacy networks, among others.

Further, each year, plans may change their premiums, benefits, and other features, and beneficiaries have the opportunity to assess these changes and switch plans during the annual open enrollment period. At the same time, people with Medicare are often inundated with marketing and advertisements for private Medicare plans – typically Medicare Advantage plans – which can add to the complexity of decision-making around Medicare choices.

KFF research has shown, however, that few beneficiaries revisit their coverage decisions each year to determine which option is best for them based on their individual needs and the specific features of the plans available to them, and few change their coverage at all: during the open enrollment period for 2020, 10% of Medicare beneficiaries with Medicare Advantage switched plans. This could be because beneficiaries are satisfied with their current coverage selection, but also may also speak to the challenges of understanding and comparing the multitude of plan options.

To better understand Medicare beneficiaries’ experience with the Medicare program, how they make their Medicare coverage choices, the factors that influence these decisions, including the role of marketing and brokers, and whether they reconsider their plan choices, KFF worked with PerryUndem to conduct a series of focus groups to provide insight on these issues (see Appendix for more details on focus groups).

Perspectives from Beneficiary Focus Groups on Medicare Coverage, Marketing, and Plan Choice

• Focus group participants said they were inundated by Medicare marketing, including unsolicited phone calls and TV ads, and believed the ads were often misleading and deceptive
• Participants found selecting Medicare coverage overwhelming and relied on brokers to assist them with their choices while few used official Medicare resources
• Participants said they considered many factors when selecting Medicare coverage, including premiums, access to doctors, extra benefits, and coverage of prescriptions
• Participants reported high satisfaction with Medicare coverage but cited specific issues that varied depending on their source of Medicare coverage
• Despite high satisfaction, participants cited specific Issues that varied depending on their source of Medicare coverage
• Participants generally feel they made the right choice when selecting a plan, and most participants have not revisited their plan choices

Experiences Unique to Dual-Eligible Participants

• Dual-eligible participants had varying experiences signing up for Medicaid coverage with some participants choosing coverage and others being assigned their coverage
• Some dual-eligible participants were concerned about the possibility of losing medicaid coverage due to the annual redetermination process

Focus Group Participants Said They Were Inundated by Medicare Marketing, Including Unsolicited Phone Calls and TV Ads, And Believed the Ads were Often Misleading and Deceptive

Private Medicare plans are allowed to engage in a variety of Medicare marketing and communication activities, including over the phone, on television, and in-person, as long as they adhere to the Centers for Medicare & Medicaid Services (CMS) rules and regulations. However, there has been concern over misleading and deceptive marketing tactics by private Medicare plans as well as third-party marketing organizations who work for these plans. For example, CMS has seen a substantial increase in beneficiary complaints in recent years – they received more than twice as many beneficiary complaints related to marketing in 2021 (~40,000) compared to 2020 (~16,000). In response to these and other concerns, CMS finalized new marketing regulations in May 2022 and in April 2023 to help protect Medicare beneficiaries who are looking for Medicare coverage.

Focus group participants were asked to provide their reactions to Medicare marketing and advertising, including over the phone and on television, whether they could tell who was sponsoring these calls or ads, what they thought about the messaging, how they felt about celebrity spokespeople in many of the ads, and if any of these communications played a role in their Medicare choices. Dual-eligible participants had similar reactions to those enrolled only in Medicare.

Unsolicited phone calls

Many participants reported getting frequent unsolicited phone calls advertising Medicare plans. Participants said marketers promoting these plans used deceitful tactics, and participants usually ignored these calls.

For marketing solicitations over the phone, private Medicare plans are subject to a number of requirements and are not permitted to use telephone solicitation (that is, cold calling), as well as robocalls, text messages, or voicemail messages if unsolicited. However, a recent report from the majority staff of the Senate Finance Committee documented robocalls, telemarketing, and frequent phone calls as a common source of complaints among Medicare beneficiaries. Most focus group participants mentioned receiving unsolicited phone calls from marketers, some of whom were calling from insurance plans or were brokers or agents representing these plans, but many participants said it was not always clear who was calling.

Confusion about TV ad sponsors

Nearly all participants have seen TV advertisements that are marketing Medicare, most frequently Medicare Advantage plans. However, many participants emphasized they were often confused who was sponsoring the ads and that many ads had the appearance of being sponsored by the government though they believed the ads were in fact sponsored by private companies.

One area of particular concern to CMS has been the use of the Medicare name and logo to give the appearance that advertisements or communications are being sponsored or endorsed by the Medicare program or the federal government, when they are actually sponsored by private Medicare plans or by representatives acting on behalf of these plans. The recent Senate Finance Committee majority staff report has also documented similar beneficiary complaints that highlight confusion over what is truly official correspondence and advertisements from the government. Likewise, a KFF analysis of Medicare TV advertising found that more than one in four ads aimed at the most recent open enrollment period, in the fall of 2022, included a government-issued Medicare card or an image that closely resembled it.

In order to address this issue, CMS has finalized changes to this type of marketing, which would prohibit the use of the Medicare name, CMS logo, or official products, including the Medicare card, in a misleading manner. Similar to these complaints, focus group participants also expressed confusion over who was sponsoring some of the ads. Many participants noted that the ads were clearly designed to give the impression they were coming from the government when they believe these ads were fact sponsored by private companies.

“Free” is not always free

One of the most common complaints among participants about TV marketing is that they often advertise that services and benefits are “free”, though this is not always true.

In many of the focus groups, participants mentioned their Medicare Advantage plans come with zero premiums and copays and access to many extra benefits, some of which give them additional money to spend, such as money for over-the-counter items. A KFF analysis of Medicare TV advertising aimed at the most recent open enrollment period, in the fall of 2022, confirmed that messaging about extra benefits was included in more than 90% of ads, while messaging about the potential for lower out-of-pocket costs was present in 85% of Medicare ads. Despite the fact that some beneficiaries report receiving these types of benefits at no cost, nearly all participants, regardless of the Medicare coverage they have, do not trust the content of these type of ads and are inclined to ignore it.

Participants feel inundated by TV ads

In general, participants feel inundated by TV ads. Most find them off-putting, misleading, and unhelpful, and say the ads did not influence their Medicare plan selections.

Celebrity spokespeople

While celebrities are often spokespeople for Medicare Advantage plans, participants did not seem swayed by them and frequently disregarded them.

KFF analysis has found that celebrity endorsements are commonly featured in TV ads for Medicare Advantage, appearing most often in ads sponsored by brokers and other third-party organizations, such as marketing firms, who may contract with insurers to promote plans and boost enrollment. Participants reported encountering these ads but most did not find the endorsements helpful or persuasive.

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Participants Found Selecting Medicare Coverage Overwhelming and Relied on Brokers to Assist Them with Their Choices While Few Used Official Medicare Resources

The average Medicare beneficiary has an average of 43 Medicare Advantage plans to choose from and 24-stand-alone prescription drug plans to choose from. Most participants said they were surprised to hear that was the average number of coverage options available and were overwhelmed at the idea of having to sort through so many plan options.

Many find the process overwhelming

Most participants said the process for selecting a plan was overwhelming and confusing to navigate. Some did try to sort through plan options themselves, but emphasized the process was challenging.

Use of Medicare insurance brokers

For this reason, many participants have used a broker at some stage to assist them when choosing their plan, and many found them helpful in sorting through the enrollment process. Many brokers were recommended by a friend or family members. For people who use brokers, they are seen as a trusted resource.

Many participants, including some dual-eligible individuals, relied on brokers to help narrow down their plan options. Medicare insurers contract with brokers to solicit and enroll beneficiaries in their plans, and in return, the brokers receive a commission from the insurer. Research has shown that people who received help making decisions about their Medicare coverage most commonly turned to brokers to help them compare and narrow down their Medicare plan options, and the focus group participants generally confirmed this trend.

Participants who used brokers said they liked that brokers simplify shopping, can ensure they choose a plan with their preferred providers, and can help navigate whether a plan covers their prescriptions. When dual-eligible participants used brokers, it was generally to help them choose a Medicare Advantage plan. In many cases, brokers were recommended to them by family and friends, who reported being happy with their plans, so participants see brokers as a trusted resource.

Beneficiaries not bothered by commissions that brokers received 

Most of the participants who used brokers did not seem bothered by potential biases or financial incentives to enroll them in a Medicare Advantage plan and relied on their advice.

Medicare brokers receive a commission for enrolling beneficiaries in plans, whether they are for Medicare Advantage, stand-alone Part D plans or supplemental Medigap plans. Yet, research has shown that brokers tend to be paid more for enrolling beneficiaries in Medicare Advantage plans rather than Medigap plans, which could create conflicts for brokers who may have an incentive to recommend one type of plan over another based on their potential compensation rather than the needs of the beneficiary. In general, beneficiaries did not seem to be aware how brokers were paid – that they might be paid by a specific insurer or receive different fees for separate products. For example, in 2020, Medicare Advantage commissions were $510 nationally, while commissions were $322 for a Medigap supplement and $78 for a Part D plan, a total commission of $400 for Medigap plus a Part D plan. However, when asked if they had concerns about any potential biases or conflicts of interest, beneficiaries did not seem bothered by the commissions that brokers received as long as they felt they were getting good recommendations on their plan options.

Few have used official Medicare information resources

Few participants have used Medicare’s official information resources such as the 1-800 Medicare toll free number, the Medicare.gov website, and the Medicare & You Handbook that is provided each year to all Medicare beneficiaries, though for the few who did, some found these resources helpful.

Medicare has official information resources beneficiaries can turn to help with their coverage decisions, including the 1-800 Medicare toll free number, the Medicare.gov website, including the Medicare Plan Finder, and the Medicare & You Handbook. KFF research has shown that these resources are not widely used, and focus group participants generally confirmed this. Participants who used these resources, however, said the resources were mostly helpful and felt they could get answers to important questions, although some participants thought the toll-free phone number, in particular, was too slow. Further, most focus group participants had not heard of or used State Health Insurance Assistance Programs (SHIPs), which provide local, in-depth, and objective insurance counseling to people on Medicare.

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Participants Said They Considered Many Factors When Selecting Medicare Coverage, Including Premiums, Access to Doctors, Extra Benefits, and Coverage of Prescriptions

When Medicare beneficiaries first enroll in Medicare and select their coverage, they are encouraged to weigh a variety of factors, including premium costs, cost sharing for services, access to specific doctors, availability of extra benefits, coverage of prescription drugs, and quality ratings of plans, among others. Beneficiaries may revisit their choice of plan each year during the annual open enrollment period.

Focus group participants were asked what factors entered into their decision making when choosing a plan, how they viewed the process of selecting a plan, and why they ultimately chose Medicare Advantage or traditional Medicare.

Many confused by coverage options and how Medicare program works

Despite looking forward to going on Medicare, many said they were confused, stressed and overwhelmed by the various coverage options and how the Medicare program works.

Many participants lacked awareness or a good understanding about the different Medicare options available to them. They mentioned confusion with the different parts of Medicare – Parts A, B, C, D – and were unclear what makes them different from each other and which parts are mandatory or optional. They often did not know which parts of Medicare were included as part of a Medicare Advantage plan and if that was the same or different as a Medicare “supplement.”

Zero or low premiums often cited as top reason for selecting a Medicare Advantage plan

For those who chose or were considering Medicare Advantage for their coverage, zero or low premiums was often cited as the top reason for selecting a Medicare Advantage plan, followed closely by low cost-sharing requirements for services.

People on Medicare are often concerned about the cost of health care because most live on fixed incomes with limited savings. When thinking about health care costs, the first thing that often comes to mind is a plan’s monthly premium, because it is monthly expense they will incur regardless of their health needs, and it is relatively easy to compare across plans. Many of the focus groups participants noted that they lived on tight budgets and could not afford to pay for coverage that required higher premiums, which may have led them to believe that Medicare Advantage seemed like a more affordable option than traditional Medicare plus a Medigap supplemental policy with an additional premium. Due to their budgets, they also looked closely at copay amounts, particularly for services that they thought they might use with some frequency.

In-network doctors are top priority

Another factor that weighs heavily in their decision-making when selecting Medicare Advantage is whether their doctors are in the plan’s network.

For people considering Medicare Advantage plans, a top priority is whether their doctors are part of the plan’s network. In many cases, people are concerned about maintaining access to their primary care physician, but depending on their health needs, some are more concerned about having access to particular specialists.

Availability of extra benefits in Medicare Advantage

An additional factor that influenced participants’ decision-making is the availability of extra benefits in Medicare Advantage such as dental and vision.

Medicare Advantage plans are able to offer extra benefits not available not offered by traditional Medicare, such as dental, vision, and hearing, as well as some that provide money to enrollees, such as over-the-counter benefits, and for this reason, many participants were attracted to Medicare Advantage plans.

Reasons for choosing traditional Medicare

Those who ultimately chose or were considering traditional Medicare (and often a Medigap supplement) liked the relatively low cost-sharing requirements, comprehensiveness of their coverage, control over their health care, and ability to see any provider they wanted.

Medigap policies, sold by private insurance companies, are supplements to traditional Medicare and fully or partially cover Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance. Medicare beneficiaries with traditional Medicare, including those with a Medigap policy, can see any provider who accepts Medicare. Medigap insurance provided supplemental coverage to 36% of people in traditional Medicare (roughly 11.5 million beneficiaries) in 2020.

Relationships with insurance providers

Some participants had relationships with insurance providers that they felt comfortable with or liked the reputation of the company.

Medicare star quality ratings

Participants did not generally use Medicare’s star quality ratings when making coverage decisions, though some participants used other non-government sources to get information about plan quality.

On the Medicare plan finder, each Medicare Advantage plan has a star rating to provide beneficiaries with additional information about the quality of plans offered in their area. All plans are rated on a 1 to 5-star scale, with 1 star representing poor performance, 3 stars representing average performance, and 5 stars representing excellent performance. When asked whether these star ratings influenced their decision-making when choosing a plan, the majority of participants said no.

For the few participants who did look at ratings, they reported turning to other non-government sources for reviews on a plan’s quality.

Prescription drug coverage important factor in decision-making

Regardless of whether they selected or were going to select traditional Medicare with a stand-alone Part D plan or a Medicare Advantage plan with drug coverage, ensuring that their prescription drugs were covered was also an important factor in participants’ decision-making.

People with Medicare can get prescription drug coverage by enrolling in a stand-alone plan that provides Part D prescription drug coverage for people with traditional Medicare or by enrolling in a Medicare Advantage plan. Coverage of prescription drugs is based on each plan’s formulary, and depending on a plan’s formulary, beneficiaries can also be subject to prior authorization, step therapy, and quantity limits. Medicare beneficiaries with Part D coverage also face cost-sharing amounts for covered drugs and may pay an annual deductible ($505 in 2023) and depending on the plan, a monthly premium.

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Participants Overall Reported High Satisfaction with Their Medicare Coverage

Most participants satisfied with Medicare coverage

Most participants – whether in traditional Medicare or Medicare Advantage – were relieved to be on Medicare and reported being satisfied with their Medicare coverage.

Medicare continues to be a very popular program, with 81% of the public holding very or somewhat favorable views of the program. Most participants mentioned being excited or relieved to go on Medicare, often because of the lower costs compared to their previous insurance coverage or because of the security of having Medicare coverage. When asked on a scale of 1-10 how they would rate their Medicare coverage, with 10 being very satisfied, most participants gave their coverage an 8, 9 or 10, saying it is working well for them.

Varied reasons for satisfaction depending on source of coverage

Participants cited a variety of reasons for their satisfaction, including costs, access to providers, and supplemental benefits, depending on their source of Medicare coverage.

Participants with traditional Medicare and a Medigap policy are generally happy with their coverage because they like the relatively low cost-sharing requirements, not having to deal with bills, protection against catastrophic expenses, ability to see any provider they want, and having control over their health care.

Medicare Advantage plan participants pleased with their coverage

Participants in Medicare Advantage plans are pleased with their coverage and noted that this was due to having zero or low premiums, and coverage of extra benefits, such as dental, vision, hearing, services and over-the-counter debit cards.

Dual-eligible participants also generally satisfied with coverage

Dual-eligible participants – whether they had Medicare coverage through traditional Medicare or a Medicare Advantage plan – are also generally satisfied with their coverage, particularly due to the low cost of their health care.

Dual-eligible individuals feel their health care coverage is affordable and covers most services they need. Most referenced the low out-of-pocket costs for their health care, such as no copays for doctor’s visits and prescriptions, as the primary reasons they were satisfied with their coverage. Some who had their Medicare coverage through a Medicare Advantage plan also were pleased at having coverage of some extra benefits, such as an over-the-counter allowance or money to buy food and produce.

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Despite High Satisfaction, Participants Cited Specific Issues that Varied Depending on their Source of Medicare Coverage

Concerns about premiums

While participants with traditional Medicare and a Medigap policy are generally pleased with their coverage and access to physicians, they had concerns about the premium.

While Medigap limits the financial exposure of Medicare beneficiaries for services covered under Parts A and B, Medigap premiums can be costly and can rise with age, depending on the state in which they are regulated. Estimated average monthly premiums for Medigap policies can range from less than $100 per month to over $300 per month depending on the plan.

High medical bills for some participants in Medicare Advantage

While many participants with Medicare Advantage are satisfied with their coverage, some with serious medical conditions encountered high medical bills when using certain services.

Delay in care experienced by some participants in Medicare Advantage

Some participants with Medicare Advantage, including some dual-eligible individuals, experienced delays receiving care due to utilization management tools, such as prior authorization and/or referral requirements.

Medicare Advantage plans can require enrollees to get approval from the plan prior to receiving a service, and if approval is not granted, then the plan generally does not cover the cost of the service. Similarly, Medicare Advantage can impose referral requirements, in which a primary doctor must provide a written letter in order for a patient to see a specialist for services, and if not provided, then the plan generally does not cover the cost. In 2023, virtually all Medicare Advantage enrollees (more than 99%) are in plans that require prior authorization for some services. Health insurers use these utilization management tools to both contain spending and prevent enrollees from receiving unnecessary or low-value services, though there are some concerns these requirements may create barriers and delays to receiving necessary care. Some Medicare Advantage participants experienced delays receiving care, but nearly all ultimately got approval for their prior authorization and/or referral requests.

Issues with provider networks 

While Medicare Advantage enrollees were generally aware of the importance of having their doctors in-network, many participants encountered situations when the doctor they wanted to see for a particular service was not in-network. Issues with provider networks was also a particular challenge for dual-eligible participants with a Medicare Advantage plan who sometimes could not find a provider who accepted both their Medicare and Medicaid coverage.

Unlike traditional Medicare, where Medicare beneficiaries can see any provider who accepts Medicare, beneficiaries enrolled in Medicare Advantage have a network of physicians and hospitals for their care. If providers are not in-network, Medicare Advantage enrollees typically must pay more to see out-of-network providers, or they may be responsible for the entire cost of seeing that provider. When beneficiaries select their Medicare Advantage plan, they are encouraged to check whether their preferred providers are in-network as provider networks vary across plans. However, evidence indicates provider directories might not always be accurate, and it may be difficult for beneficiaries to compare networks and providers across plans as they may be in different formats across insurers. Focus group participants noted situations when they could not see their preferred doctor because they were not in their plan network and were frustrated with having to see a different provider.

In addition, some dual-eligible participants with a Medicare Advantage plan, including participants with a dual-eligible Special Needs Plan (D-SNP), reported issues with doctors accepting their health insurance policy. D-SNPs are a specific type of Medicare Advantage plan designed for this population to better coordinate care, though these plans can also look different across states in terms of their levels of coordination. For example, some D-SNPs offer Medicaid and Medicare benefits through different organizations, while some have plans through the same parent company.

Frustration with using some supplemental benefits

Some Medicare Advantage enrollees also voiced frustration with using some supplemental benefits, particularly dental coverage, because cost sharing was higher than expected and due to network restrictions. Network restrictions for extra benefits were also challenging for dual-eligible participants who had a Medicare Advantage plan.

Many people are attracted to Medicare Advantage plans because they offer extra benefits that traditional Medicare does not offer, such as dental, vision, and hearing coverage. However, some participants raised concerns with the costs of these benefits, challenges using these benefits, or finding a provider who covered these services. Like accessing providers covered by Medicare Advantage plans, many Medicare Advantage plans have networks of providers who cover supplemental benefits, or the enrollee will be required to pay more to see someone out-of-network, such as for dental benefits.

Frustration with high cost of certain medications

Some participants were also frustrated by the high cost of certain medications, particularly for those who need specific drugs to manage chronic conditions.

In recent years, many Medicare beneficiaries have experienced high out-of-pocket costs for their prescription drugs. Changes as part of the Inflation Reduction Act, including a $35 monthly copay on insulin that went into effect in 2023, as well as limits on out-of-pocket prescription drug spending in Part D beginning in 2024, and a $2,000 cap beginning in 2025, will help some Part D enrollees with their prescription drug costs.

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Participants Generally Feel They Made the Right Choice When Selecting a Plan, and Most Participants Have Not Revisited Their Plan Choices

The marketplace of Medicare private plans is based on the idea that beneficiaries will compare their plan options to find plans that best meet their individual needs. CMS encourages beneficiaries to compare and review their plan options each year, which could enable them to receive care at a lower cost, ensure their preferred providers are in network, and that the prescription drugs they take are covered. However, KFF analysis has shown that most beneficiaries do not compare their plan options in each year.

Majority feel they made the right choice

The majority of participants in the focus groups confirmed this behavior – they explained that they felt that their coverage was comprehensive and did not need to reevaluate their coverage every year though some wish they had more information before enrolling. Additionally, many participants said they are unlikely to switch plans going forward because selecting a new plan would be too much work, and they did not feel confident they would be better off with another type of coverage. For dual-eligible participants who made a choice about their Medicare coverage, they also generally did not feel the need to switch plans going forward.

But some say they shop around

However, a few of the participants said they do shop around, sometimes every year, to ensure they continue to have the best plan that meets their needs.

Experiences Unique to Dual-Eligible Participants

People with both Medicare and Medicaid, also referred to as dual-eligible individuals or dual eligibles are enrolled in both programs and must meet eligibility requirements for both programs. They receive their primary health insurance coverage through Medicare and some assistance from their state Medicaid program. Together, these two programs help to shield low-income beneficiaries from potentially unaffordable out-of-pocket medical and long-term care costs: Medicaid typically pays the Medicare Part B premium and may also pay for Medicare’s other cost-sharing requirements; Medicaid also helps pay for services that are not covered by Medicare, such as long-term services and supports. While nearly all dually eligible beneficiaries have low incomes and very modest savings, they are otherwise a diverse group in terms of age and physical and mental health.

To capture the unique experiences faced by dual-eligible individuals, we conducted two focus groups that consisted exclusively of these beneficiaries.

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Dual-Eligible Participants Had Varying Experiences Signing Up for Medicaid Coverage With Some Participants Choosing Coverage and Others Being Assigned Their Coverage

As mentioned above, people with Medicare have the choice between traditional Medicare or a Medicare Advantage plan, which can include an individual plan open for general enrollment as well as a dual-eligible Special Needs Plan (D-SNP). Dual-eligible individuals who are eligible for full Medicaid may receive those Medicaid benefits through capitated managed care organizations (MCOs) or through fee-for-service (FFS). Options for Medicaid coverage vary depending on the state that the enrollee lives in as do the mechanisms for beneficiary enrollment. Some states provide dual-eligible individuals with the ability to choose their plans, others assign people to a plan, and still others assign enrollees to a plan but offer them the opportunity to disenroll and select a different option.

As a result, participants had varying experiences signing up for Medicaid coverage, often depending on the state they lived in and whether they had enrolled in Medicare or Medicaid first or at the same time.

Making a choice for Medicaid coverage

Some participants had to make a choice for their Medicaid coverage, and many had help from the state choosing their plan.

Some participants did not have a choice

Some participants did not have a choice of their Medicaid coverage, or someone enrolled them in Medicaid coverage – often the state or county chose their Medicaid plan for them.

Some Medicare enrollees did not realize they might also be eligible for Medicaid

Some who were enrolled in Medicare did not realize they might also be eligible for Medicaid, but their state reached out to them to let them know they should apply for Medicaid coverage.

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Some Dual-Eligible Participants Were Concerned About the Possibility of Losing Medicaid Coverage Due to the Annual Redetermination Process

Concerns about redetermination process

Because of the importance of the Medicaid program for addressing their health care needs, some dual-eligible participants were concerned about the redetermination process and anxious about the possibility of losing that coverage.

Prior to the COVID-19 pandemic, states were required to renew Medicaid eligibility for dual-eligible individuals at least once per year. Since March 2020, states have provided continuous enrollment in Medicaid in exchange for enhanced federal funding. This continuous enrollment provision and enhanced federal funding were originally in place until the end of the COVID-19 public health emergency (PHE). In December 2022, the Consolidated Appropriations Act, 2023 (CAA) delinked the provision from the PHE and ended continuous enrollment on March 31, 2023. Beginning April 1, 2023, states have restarted disenrollments after conducting a full review of eligibility. As states begin to “unwind” the continuous enrollment provision, many people will likely be found to be no longer eligible for Medicaid. Others could face administrative barriers and lose coverage despite remaining eligible.

Focus group participants generally had not experienced a loss of Medicaid, but some participants mentioned being concerned with losing their Medicaid coverage in the future due to changes in their incomes, assets, or other eligibility requirements. Many were aware of the renewal requirements even though redeterminations had been on hold during the pandemic.

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