Facilitating Community Transitions for Dually Eligible Beneficiaries

Michelle Herman Soper
Hannah-Dulya Menelas
Case Example
December 2019


Details how two health plans in California developed programs to transition dually eligible members from institutional settings back into their communities.


More than 40 percent of dually eligible individuals, those eligible for both Medicare and Medicaid, rely on long-term services and supports (LTSS) to meet their daily care needs. Supporting those in need of LTSS to live in a community rather than institutional setting can help to meet individual and family preferences, align with the American Disabilities Act, and reduce state spending. This case study shows how two health plans in California, Health Plan of San Mateo and Inland Empire Health Plan, created programs to transition dually eligible members in need of LTSS from nursing facilities to their communities.


The two programs focused on locating eligible individuals, managing transitions, and providing post-transition services. Both plans encountered barriers to transitioning individuals such as a lack of affordable housing and complex transition needs for the patients. Health Plan of San Mateo’s program successfully transitioned 300 members to community settings, which decreased the per member per month costs by 35 percent. Member satisfaction was also high.


This case study offers helpful examples for health plans, policymakers, providers, or states seeking to implement a similar model of transitioning individuals from an institution back into the community.

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