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For people enrolled in both Medicare and Medicaid, getting behavioral health care is rarely straightforward. A trip to the emergency room, a follow-up outpatient visit, or a stay in residential treatment may each be covered by a different program, leaving patients to navigate shifting and often complicated rules.
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A new analysis co-authored by health economist Jeah Jung of the George Mason College of Public Health examines how this overlap plays out in practice. The research, published in JAMA Network Open, focuses on dual-eligible individuals—low-income patients enrolled in both Medicare and Medicaid—through special needs plans (D-SNPs).
Researchers found that for acute behavioral health care, including emergency services, Medicare often covers costs. For longer-term or community-based support, Medicaid often pays for services.
“These dual-eligible individuals don’t experience their care from a single payer,” Jung said. “The way that responsibilities are divided can create a fragmented and complicated experience for people trying to access behavioral health care.”
Why this matters
The study shows that behavioral health conditions—including mental health and substance use conditions—are prevalent among DSNP enrollees. But care for these millions of patients is not delivered through a single, coordinated system.
Depending on where care is provided, responsibility shifts between Medicare and Medicaid. As patients move through that continuum, they may encounter different rules and sources of coverage, making behavioral health care harder to coordinate.
Study details
The study analyzed 2021 Medicare Advantage and Medicaid claims for more than 1.6 million D-SNP enrollees. Jung collaborated with a research team based at Oregon Health & Science University, examining how common behavioral health conditions were and how services were paid across different care settings, including emergency departments, inpatient care, outpatient visits, telehealth, and residential treatment.
Key findings include:
Behavioral health conditions are widespread in this population, with 61.5% of enrollees under age 65 and 42.7% of those 65+ reporting at least one condition.
Medicare dominates acute care, covering most emergency department visits and a larger share of hospital stays.
Medicaid covered most residential treatment and a substantial share of outpatient, community-based services.
About 31% of enrollees used behavioral health services paid by both programs.