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🔗 '''Medicare-Medicaid plan''' is a type of U.S. [[Definition:Managed care | managed care]] product designed for individuals who are simultaneously eligible for both [[Definition:Medicare | Medicare]] and [[Definition:Medicaid | Medicaid]]—commonly referred to as "dual-eligible" beneficiaries. These plans, sometimes called dual-eligible special needs plans (D-SNPs) or Medicare-Medicaid Plans (MMPs) depending on the specific program structure, integrate the benefits of both federal and state programs into a single plan administered by a private [[Definition:Insurance carrier | insurer]]. The goal is to replace the fragmented coverage that dual-eligible individuals would otherwise navigate across two separate government programs, each with its own provider networks, formularies, and administrative requirements.

⚙️ Under these arrangements, a participating [[Definition:Health insurance | health insurer]] contracts with both the Centers for Medicare & Medicaid Services (CMS) at the federal level and one or more state Medicaid agencies. The insurer receives [[Definition:Capitation | capitated]] payments from both programs and, in return, assumes responsibility for coordinating the full spectrum of medical, behavioral health, and long-term care services. Operationally, this demands sophisticated [[Definition:Care management | care management]] capabilities, because dual-eligible beneficiaries tend to have complex chronic conditions and high utilization rates. Insurers must also reconcile two distinct sets of regulatory requirements—federal Medicare rules and state Medicaid standards—which can differ on everything from [[Definition:Network adequacy | network adequacy]] to [[Definition:Grievance and appeals process | grievance and appeals processes]].

💡 Dual-eligible beneficiaries represent a disproportionately expensive segment of both Medicare and Medicaid spending, making this population a focal point for cost-containment policy. For insurers, Medicare-Medicaid plans offer access to a substantial premium pool backed by government funding, but the [[Definition:Medical loss ratio (MLR) | medical loss ratios]] tend to run high and the administrative complexity is significant. Carriers that succeed in this space—typically large national or regional managed care organizations—build competitive advantages through integrated data platforms, specialized provider partnerships, and deep experience with [[Definition:Risk adjustment | risk adjustment]] methodologies. While this plan structure is specific to the U.S. healthcare system, the broader concept of integrating multiple public benefit streams into a single managed product has parallels in markets like the Netherlands and Israel, where private insurers administer compulsory social health insurance schemes.

'''Related concepts:'''
{{Div col|colwidth=20em}}
* [[Definition:Medicare]]
* [[Definition:Medicaid]]
* [[Definition:Managed care]]
* [[Definition:Capitation]]
* [[Definition:Risk adjustment]]
* [[Definition:Medicare Advantage]]
{{Div col end}}

Definition:Medicare-Medicaid plan - Revision history

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