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Dual Eligibility: Finding a Specialty Benefits Solution That Fits

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When you’re evaluating strategies for streamlining specialty benefits administration, look for solutions that address the complexities of dual eligibility. Dual eligibility most often refers to members that are enrolled in both Medicaid and Medicare programs. In some cases, it can refer to members enrolled in two different commercial plans. In 2020, 12.5 million Americans were Medicare-Medicaid enrollees. 

Dual eligibility can lead to significant challenges for payers if it isn’t properly applied. These challenges include: 

  • Issues with claims payments - Failure to properly identify and coordinate claims for members with dual eligibility results in costly overpayment scenarios and causes provider dissatisfaction.
  • Compromising on member experience - Inaccurate processing may lead to a second or surprise bill for members, which can lead to members’ frustration with their plan, especially if dual eligibility rules aren’t explained in a way that members can understand. 

Some benefit management platforms support dual-eligible members in a pre-defined way, but if the technology doesn’t align to your specific definitions and business rules for dual eligibility, the manual work and risk to your member experience will still exist. 

The ideal solution? A specialty benefits automation platform like SKYGEN’s Enterprise System. SKYGEN automates dual eligibility for unique scenarios without the expense, complexity and time-cost of customized technology.  

Flexible Configuration is Key 

An advanced platform that’s highly configurable can support multiple dual scenarios and put the rules around them without creating a custom solution for specialty benefits administration. 

Types of dual scenarios that an advanced system should handle include:

  • Members covered by Medicare and Medicaid – the most common type of dual eligibility 
  • Members covered by Medicaid in both D.C. and in Maryland (for national plans)
  • Members covered by commercial and Medicare plans (i.e., retirees)  
  • Members covered by two different commercial plans – some health plans define this  coordination of benefits as dual eligibility 
  • Members with tertiary coverage: Less common but still occurring, especially with minor children. Some instances of tertiary coverage include a child of divorced parents where the minor is covered by both parents’ health plans as well as a stepparent’s plan; and cases where both parents and their 18-year-old child work for the same employer and are covered by separate plans.

If you’ve expanded or plan to expand into government programs, look for a highly user-configurable, scalable specialty benefits administration platform. In addition to the benefits of rules-driven claims processing for your organization, you’ll also create advantages for your stakeholders:

  • Providers should only need to submit one claim, and payment still occurs quickly. The system takes the burden of extra administration and communication off providers’ staff. 
  • Members’ claims should be processed quickly and accurately the first time, and a clear, understandable explanation of benefits provided. The complexity of dual eligibility is removed to create a more member-centric experience.

If you’d like to learn more about specialty benefits administration systems that can handle these complex scenarios, contact SKYGEN today. 

Learn how you can transform the delivery of health benefits with SKYGEN.