The Variation in Dual-Eligible Beneficiary Characteristics across Medicare Advantage Plan Types

Enrollment in Medicare Advantage (MA) plans among full-benefit dual-eligible beneficiaries has risen. These individuals that qualify for and have enrolled in both Medicare and full Medicaid has gone up, which is also a reflection of the greater Medicare group.¹

MA, which is considered the managed care alternative to traditional Medicare, is overseen by private insurers who receive risk-adjusted, capitated payments to deliver Medicare-covered services to enrollees. The numbers show that in 2019, 36% of full-benefit dual-eligible beneficiaries were signed up for MA, and by 2022, nearly 50% of dual-eligible beneficiaries who had full Medicaid were also enrolled in MA.¹

Overview of Medicare Advantage plan types for dual-eligible beneficiaries

Full-benefit dual-eligible beneficiaries are allowed to enroll in different MA plan types. They differ in their obligations when it comes to handling care with Medicaid and handling spending. For this particular study¹ published in JAMA Network Open, investigators broke analysis down into four types of plans:

1. Standard MA Plans: Cover only Medicare services, such as outpatient, acute/postacute care, prescription drugs); do not coordinate with Medicaid and can enroll both dual-eligible and non–dual-eligible beneficiaries
2. Dual-Eligible Special Needs Plans (D-SNPs): Exclusively enroll dual-eligible beneficiaries; can only contract with and coordinate care through state Medicaid programs, and can directly manage some Medicaid-funded services
3. D-SNP Look-Alike Plans: Considered the standard MA plans primarily serving dual-eligible beneficiaries, but they lack the formal D-SNP requirements, including Medicaid contracts and care coordination. They are not subject to D-SNP regulations.
4. Fully Integrated Dual-Eligible Special Needs Plans (FIDE-SNPs): Considered a subset of D-SNPs, they operate under capitation contracts for Medicaid long-term care and often, behavioral health services. They provide the highest level of Medicare-Medicaid integration.

Essentially, the investigators sought to determine how characteristics of dual-eligible beneficiaries with full Medicaid differ across the various Medicare Advantage (MA) plans above.

Study design and methodology

The cross-sectional study captured data from the 2017 to 2019 Medicare Health Outcomes Survey (HOS), which gathered respondent-reported health, demographics, and social characteristics, using random sampling to survey a representative group of beneficiaries enrolled in MA organizations. Per protocol, each baseline survey has at least 500 participants, and a follow-up survey is given two years later.

Although the HOS does not feature survey weights to account for any nonresponses, the response rate among full-benefit dual-eligible beneficiaries was 29%. The investigators utilized the Medicare Beneficiary Summary File (MBSF)—which is connected to the HOS at the beneficiary-year level—in order to determine the dual-eligible MA enrollees and enrollment in aforementioned four plan types.

Statistical analysis approach, key findings and beneficiary characteristics

When it came to statistical analysis, the study examined beneficiary-year data from that 2017 to 2019 timeframe to compare characteristics of full-benefit dual-eligible Medicare Advantage (MA) enrollees across different plan types, with a focused subsample in counties where FIDE-SNPs were available. The researchers used multinomial logistic regression, beginning with the bivariate models, followed by the multivariate models, while disregarding ADI because of collinearity. The goal was to predict the likelihood of enrollment by plan type, controlling for state-fixed effects. These analyses were conducted from January 2024 to January 2025, with statistical significance set at p < .05.

The study consisted of a total 147,923 full-benefit dual-eligible beneficiaries (mean [SD] age 67.7 [13.9] years; 63.4% female), that were enrolled in FIDE-SNPs (25,755), coordination-only D-SNPs (65,220), D-SNP look-alike plans (5,193), and standard MA plans (51,755). Overall, 9.6% were 85 years of age or older, and 6.5% were living with a caregiver. On a 0–12 scale, beneficiaries had an average of 4.2 comorbidities and 2.3 difficulties with activities of daily living.

Meanwhile, FIDE-SNP enrollees had the highest levels of need, given that 59.0% were aged 85 or order, 56.6% lived with a caregiver, had a mean of 4.6 comorbidities, and 3.1 difficulties with daily activities; this was compared to 16.1%, 15.3%, 4.1, and 2.1 respectively in coordination-only D-SNPs. For counties that only provided FIDE-SNPs, 41.3% of individuals in the most socioeconomically disadvantaged areas and 43.2% in the least disadvantaged areas were enrolled in FIDE-SNPs, with most differences persisting in multivariate models.

“This cross-sectional study highlights the substantial differences in characteristics among full-benefit dual-eligible beneficiaries enrolled in various MA plan types,” the study investigators explained. “We found that while these beneficiaries had substantial health and social risk factors overall, those enrolled in FIDE-SNPs were generally older, had higher levels of frailty and comorbidities, and were more likely to live alone or with a paid caregiver compared with those in other MA plans types. However, FIDE-SNP enrollees tended to live in less socioeconomically deprived areas. These findings underscore the importance of tailoring policy efforts to address the unique needs of different dual-eligible populations within MA and highlight the need for further research to understand the factors influencing MA plan choices among dual-eligible beneficiaries.”

Reference

1. Offiaeli K, Meyers DJ, Macneal E, Johnston KJ, Brown-Podgorski B, Roberts ET. Patient-Reported Characteristics Across Dual-Eligible Medicare Advantage Plan Types. JAMA Netw Open. 2025;8(4):e255791. doi:10.1001/jamanetworkopen.2025.5791