Aligning Medicaid and Medicare Advantage Managed Care Plans for Dual-Eligible Beneficiaries

Laura M. Keohane
Zilu Zhou
David G. Stevenson
Peer-Reviewed Article
April 2021


Aligned Dual-Eligible Special Needs Plan (D-SNP) enrollment was associated with more efficient service use among some dually eligible beneficiaries.


Individuals who are dually eligible for Medicare and Medicaid must navigate across separate systems for coverage of their medical care, long-term services and supports, and behavioral health needs, leading to poorly coordinated and inefficient care. Many states have sought to increase coordination between Medicare Advantage D-SNPs and Medicaid managed care plans by facilitating enrollment into aligned plans operated by the same insurer. This study evaluated the impact of enrollment in aligned D-SNPs in Tennessee, which required all insurers offering a Medicaid plan to also offer a D-SNP beginning in 2015.



After Tennessee implemented this policy, the percentage of dually eligible beneficiaries enrolled in aligned D-SNPs grew from seven percent to 24 percent. Enrollment in aligned D-SNPs was associated with decreased inpatient admissions and prescription drugs per month for beneficiaries age 65 and older. Aligned D-SNP enrollment, however, was associated at the county level with increased inpatient admissions for beneficiaries younger than 65. These mixed findings reflect previous findings on other initiatives designed to align Medicare and Medicaid enrollment, such as in the federal Financial Alignment Initiative. Notably, many individuals opted to join a D-SNP that was unaligned, meaning not operated by the insurer of their Medicaid managed care plan. This finding suggests that coverage factors such as Medicare provider networks may be more important for beneficiary decision-making than benefit alignment.


Tennessee substantially increased enrollment in aligned D-SNPs through this state policy change. While aligned D-SNPs in Tennessee showed modest success in reducing inpatient and institutional care among older beneficiaries, this approach was less effective with younger beneficiaries and nursing home residents. Federal and state policymakers should apply this evidence to inform future initiatives on aligned D-SNPs.

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