What is a dual eligible patient?

A dual eligible patient is a person who qualifies for both Medicare and Medicaid, and is given further assistance and care through these programs in order to provide coverage for their complex medical and financial situations that require more specific attention. About 9 million Americans are covered by both Medicare and Medicaid . Over 5.6 million dual eligible patients are over the age of 65. Another 3.6 million patients are under 65, but have major disabilities. Unfortunately, dual eligible beneficiaries are often poorer in health and require more expensive treatment options. The dual eligible population is far from homogeneous. They have a wide range of conditions, circumstances, and health care needs. Some, often described as “high need” or “high cost,” have extensive need for acute, post-acute, and long-term care services and supports. Other dual eligibles, while low income and qualify for Medicaid in addition to Medicare, use relatively few services and have lower than average Medicare costs. According to the Kaiser Family Foundation, the majority of dual eligibles have multiple chronic conditions, and many are in poor health with physical disabilities or mental disorders.

What’s covered?

Some of the basic offerings that are covered for dual eligibles are physician services, prescription drugs, hospitalizations, nursing facilities, hospice care, home visits, and more. Medicare covers the majority of services, but Medicaid is utilized in services that are not covered by Medicare. The objective of this system is that dual eligible beneficiaries are provided with treatment for their complex medical needs, raising the quality of their care, and reducing the overall costs of expensive treatments. Often times, these patients require costly treatments, making them a heavy burden on taxpayers. Another drawback of this program is that not all beneficiaries may receive the coverage needed based on their illness. They often get automatically enrolled in programs that might not take their specific healthcare needs into account. Despite the importance of the services that Medicare and Medicaid cover, the current system creates inefficiencies for dual eligibles.

How can developing a relationship with dual eligible patients benefit pharmacists?

Dual eligible beneficiaries can impact pharmacies in a positive way. One of the major provisions of Medicare Part D regulations is that the government requires the state to continue to pay for certain prescription drugs and even over-the-counter medications for dual eligibles. These medications were covered by Medicaid, but are not covered by the Part D programs. This allows patients to receive the medications they need, and pharmacies to receive better reimbursements. The Part D program protects low-income beneficiaries from high costs, while ensuring that they have access to medications. A 2013 KRC Research survey found a 96% satisfaction rate among dual eligibles with the Part D drug program due to its success in limiting dual eligibles’ out-of-pocket drug costs.

Additionally, the automatic enrollment in Medicare Part D plan for these patients allows them to have access to expensive medications. In turn, this benefits pharmacies as they are able to bill the state to cover costs. The dual eligible option is ideal for those who cannot afford to treat their severe medical conditions and must seek further assistance as an extension to basic Medicare or Medicaid coverage. However, these benchmark plans that dual eligible patients are automatically assigned to are not always the most affordable for the patient. Often they do not take into account a patient’s current medical conditions. In addition, these plans may not have great reimbursements for the pharmacist. However, a pharmacist can find a plan that is beneficial to both patient and the pharmacy. Unlike standard Medicare Part D coverage, dual eligible patients can switch their plans at any time of the year. Pharmacists have the opportunity to take an active role in helping these vulnerable patients receive the most affordable care by providing information on the most financially viable plan, while also potentially generating more income for their pharmacy.