Adults with special needs, severe mental illness, and adult autism require a comprehensive and multifaceted approach to care coordination to improve their health outcomes. Sometimes referred to as “BCNs” (Beneficiaries with Complex Needs), these individuals typically have multiple chronic conditions, disabilities, or severe mental illnesses that result in high healthcare utilization and costs.
Often, BCNs are dual-eligible adults requiring effective care coordination that involves several specific healthcare needs that can significantly enhance their quality of life. Dual-eligible adults are individuals who qualify for both Medicare and Medicaid benefits. This dual eligibility typically applies to low-income seniors and younger individuals with disabilities who meet the criteria for both programs.
The integration of Medicare and Medicaid benefits aims to provide comprehensive coverage that addresses a wide range of healthcare needs for the BCN population.
Critical Characteristics of Dual-Eligible Adults
- Income and Asset Limits: Dual-eligible adults usually have limited income and assets, meeting the financial eligibility criteria for Medicaid and qualifying for Medicare due to age or disability.
- Comprehensive Coverage Needs: They often have complex healthcare needs, including multiple chronic conditions, mental health issues, and long-term care requirements.
- Vulnerable Population: This group is considered highly vulnerable due to their health status, socioeconomic factors, and the need for coordinated care across various services.
Types of Dual-Eligible Adults
- Full Benefit Dual Eligibles (FBDEs): These individuals receive full Medicaid benefits and Medicare. Medicaid covers services not covered by Medicare, such as long-term care, dental care, and transportation.
- Partial Benefit Dual Eligibles: These individuals receive assistance with Medicare premiums and cost-sharing but do not receive the total Medicaid benefits. There are specific programs under this category, including:
- Qualified Medicare Beneficiary (QMB) Program: Pays for Medicare Part A and B premiums, deductibles, coinsurance, and copayments.
- Specified Low-Income Medicare Beneficiary (SLMB) Program: Pays for Medicare Part B premiums.
- Qualifying Individual (QI) Program: This program also helps pay Medicare Part B premiums.
- Qualified Disabled and Working Individuals (QDWI) Program: Pays for Medicare Part A premiums for specific disabled individuals who have returned to work.
Dual-eligible individuals often face multiple chronic health conditions requiring coordinated and continuous care. They are more likely to use emergency room services, hospitalizations, and long-term care facilities. Navigating the benefits and services covered by Medicare and Medicaid can be challenging, leading to fragmented care. These individuals may face barriers such as housing instability, food insecurity, and lack of transportation, which can impact their overall health and access to care. They are also often afraid to engage in preventive and therapeutic services due to fears from past experiences and language and communication limitations.
Integrated care models and programs can provide more coordinated and comprehensive care for dual-eligible adults and address these challenges. These include Dual Eligible Special Needs Plans (D-SNPs) designed to integrate Medicare and Medicaid benefits and provide comprehensive, coordinated care for dual-eligible individuals. Program of All-Inclusive Care for the Elderly (PACE): PACE programs offer coordinated medical and social services for older adults, allowing them to live in the community while receiving comprehensive care. Integrated Care Initiatives: These initiatives aim to integrate better Medicare and Medicaid services, such as the Financial Alignment Initiative, which aims to align financing and service delivery between the two programs.
At KemeticHlth, our work can benefit dual-eligible adults with severe mental illness facing barriers in accessing regular primary and preventive care, leading to unmanaged chronic conditions and frequent emergency room visits. KemeticHlth Care Coordination Solutions include:
- Health Education and Promotion: Provide education on healthy lifestyle choices, medication adherence, screenings, and self-care practices to empower individuals to manage their health actively.
- Case Management Services: Employ dedicated case managers who work closely with patients to identify and coordinate necessary social services, such as housing assistance, food security, and transportation.
- Community Resource Navigation: Create partnerships with community organizations to facilitate access to resources like vocational training, educational programs, and social activities that promote independence and social inclusion.
- Family and Caregiver Support: Provide support and education for family members and caregivers, including respite care, to reduce caregiver burnout and ensure the patient’s support network is well-informed and capable of providing adequate care.
- Assistance with Daily Living: Coordinate in-home support services for activities of daily living (ADLs), such as bathing, dressing, and meal preparation, to enhance the individual’s ability to live independently and safely.
Addressing the complex healthcare needs of dual-eligible adults with moderate to severe mental illness through tailored care coordination can significantly improve health outcomes and quality of life.
At KemeticHlth, we are advancing comprehensive behavioral health management solutions, enhanced access to primary and preventive care, and robust social and community support services for better overall health for this vulnerable population.