NHC Response to Duals RFI


NHC Response to Duals RFI (PDF)

January 13, 2023

The Honorable Bill Cassidy, M.D.
United States Senate
Washington, DC 20510

Dear Senator Cassidy:

The National Health Council (NHC) is pleased to provide the following response to the RFI issued by you and your colleagues on how to improve coverage for individuals jointly enrolled in Medicare and Medicaid. We commend you for the serious questions you raise concerning this important issue. People who are dually eligible for these critical health programs are typically individuals with the most significant health and financial concerns. We must work together to create a system that supports people who are among our nation’s most vulnerable.

Created by and for patient organizations more than 100 years ago, the National Health Council (NHC) brings diverse organizations together to forge consensus and drive patient-centered health policy. We promote increased access to affordable, high-value, sustainable health care. Made up of more than 150 national health-related organizations and businesses, the NHC’s core membership includes the nation’s leading patient organizations. Other members include health-related associations and nonprofit organizations including the provider, research, and family caregiver communities; and businesses representing biopharmaceutical, device, diagnostic, generic drug, and payer organizations.

The following is our response to some of your specific questions.

Coverage Needs

The fourth and fifth question of the RFI ask about the needs of individuals and whether it would be better to work to improve the existing system for people who are dually eligible or work to create a new system. The important thing to consider when asking this question is that no matter what a future system is, the needs of people who are dually eligible must be met. The reason people need access to both Medicare and Medicaid is because they have unique coverage needs that neither program alone can meet. This includes the need for prescription drug coverage from Medicare and access to long-term services and supports under Medicaid. Regardless of the future, people who are dually eligible should have access to medical care including prescription drug coverage, long-term services and supports, and myriad other services.

Care Coordination

The first question focuses on how to define and implement care coordination. This is one of the largest concerns from a patient perspective. People who are dually eligible must navigate two separate programs with different rules and coverage options for different types of care. In addition, the reality that these two systems are financed in two different ways by both Federal and State government entities can be a struggle both for providers and patients, but also in systemic efforts to improve care and manage costs. The NHC believes that care must be better coordinated systemically and for individual patients.

One critical need is to assure that care is coordinated and personalized to the individual. The system we have set up requires people with the most significant health needs to navigate one of the most complex systems of coverage. There is a significant need for assistance in navigating this system and for coordinating care for an individual. One issue is that we do not have care coordination staff that truly understand the complexity of navigating care for dual eligibles. A recent Commonwealth Fund focus group illustrated this[1]. A state official in Ohio said, “[I]t’s tough when we expect care managers to be a central point of integration. . . . It’s difficult to find staff that can adequately convey and understand the different systems across the entire spectrum and understand long-term care, behavioral health, and medical care, and be able to work on behalf of the individual in all of those spaces.” We need to develop a pipeline of people with this expertise, support them, and make them available to patients.

Medicaid Eligibility Concerns

In the tenth question, you ask about alternatives to individuals spending down assets to qualify for Medicaid. While it would absolutely be preferable that people are not forced to impoverish themselves to access Medicaid, it is a reality that Medicaid offers needed services that Medicare does not. While offering Medicare Advantage (MA) supplemental benefits to fill in the gap might work for some individuals, MA plans do not have the experience or resources to provide the full spectrum of potential long-term services and supports that some dual eligible individuals may require. To transition these services to Medicare Advantage supplemental benefits may or may not be feasible, and it would be critical that it be done carefully and with a specific goal of assuring that the full array of services needed by individuals would be available.

Equity for Dual Eligibles

The NHC appreciates that you included the eighth question on ensuring reforms consider the diversity of the dually eligible population and are sufficiently targeted to ensure improved outcomes across each sub-group of beneficiaries. It is critical that we collect demographic data that is consistent and comprehensive across systems. The HHS Implementation Guidance On Data Collection Standards For Race, Ethnicity, Sex, Primary Language, And Disability Status[2] should be consistently and fully used so that data can be accurate, granular, and disaggregated.

Another equity consideration to take into account is addressing social drivers of health. People who are dually eligible for Medicare and Medicaid are much more likely than other Medicare beneficiaries to have significant economic and social concerns such as unstable housing, food insecurity or issues with transportation needed to access health care. As a result, their health outcomes are often poorer, and health care spending often higher[3]. Exploring system-wide ways of tracking and addressing these needs would benefit both patients and the system. This can include greater use of Z codes, utilizing Medicare Advantage supplemental benefits, and linking Medicare and Medicaid enrollment processes with those for other government-funded support programs.


Please do not hesitate to contact Eric Gascho, Senior Vice President of Policy and Government Affairs if you or your staff would like to discuss these issues in greater detail. He is reachable via e-mail at [email protected].


Randall L. Rutta
Chief Executive Officer


[1] Improving Care Individuals Dually Eligible Medicare Medicaid FAI | Commonwealth Fund

[2] https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//43681/index.pdf

[3] Addressing Social Determinants of Health Needs of Dually Enrolled Beneficiaries in Medicare Advantage Plans (hhs.gov)