Putting Data to Work for Older People 

RESEARCH BRIEF NUMBER 7 • NOVEMBER 2014

OAA Service Users: 

Who Is At Risk for Becoming Medicare-Medicaid Eligible?

by Niranjana Kowlessar, Kristen Robinson, and Claudia Schur, Social & Scientific Systems, Inc.

Since passage of the Older Americans Act (OAA) in 1965, the Administration on Aging (AoA) has supported the 

delivery of services to Americans aged 60 and over and their caregivers, helping them maintain independence and 

remain in their own homes. Through its “Aging Services Network” including State Units on Aging (SUAs), Area 

Agencies on Aging (AAAs), local service providers, and tribal partners, AoA works to provide services designed to 

mitigate the effects of declining physical health and functioning experienced by frail adults aged 60 and over. This 

brief, the seventh in a series that presents findings from AoA’s National Survey of OAA Participants, explores the use of 

community-based services among OAA Title III program recipients at risk of becoming eligible for Medicaid.

Summary

Individuals enrolled in both Medicare and Medicaid 

services are often more frail and more costly to care 

for than Medicaid-only enrollees. Across Title III 

services funded by the Older Americans Act (OAA), the 

percentage of adults aged 60 and over receiving both 

Medicare and Medicaid benefits ranges from 16 percent 

among people receiving congregate nutrition services 

to 38 percent among those receiving case management 

services. To learn more about this population, this brief 

examines OAA service recipients by program utilization and certain health and economic characteristics that 

may lead to adults aged 60 and over becoming eligible 

for Medicaid. OAA participants not currently receiving 

Medicaid are classified into two groups: first by income 

(impoverished vs. not impoverished), and second by 

health status (frail vs. not frail). Findings suggest that 

classifying OAA service recipients by income or health 

characteristics (the two main reasons that Medicare 

participants become eligible for Medicaid) may help us 

to better understand how the proportion of adults aged 

60 and over who may be at risk of becoming eligible for 

Medicaid differs by OAA program participation. It also 

demonstrates that those who are at risk for becoming 

eligible for Medicaid are already receiving programs 

and services designed to help them stay in their homes 

and communities.

Background

The majority of adults aged 65 and over (93 percent) 

living in the community, have Medicare as their 

primary source of health insurance (DeNavas-Walt, 

Proctor, and Smith 2013). Medicare covers acute care 

services (inpatient hospitalizations and other shortterm care) and some post-acute care (care provided 

in settings such as skilled nursing facilities). In 2008, 

Medicare paid for approximately 60 percent of the 

health care costs of people age 65 and over. The 

remaining health care costs were either paid for by 

supplementary health insurance policies or out of 

pocket by the consumer (Federal Interagency Forum on 

Aging-Related Statistics 2012). One source of supplementary health insurance that is being relied upon more 

The Aging Services Network (funded under Title 

III of the Older Americans Act) provides a range 

of community-based services – home-delivered 

and congregate nutrition services, case management, transportation, and homemaker and caregiver 

support to individuals age 60 and over and their 

caregivers. These services are intended to reach the 

most vulnerable older adults in greatest social and 

economic need. Such services enhance both the 

quality of life and social interaction, and minimize 

the impact of disability.

What Is the Aging Services Network?
2

and more by adults aged 65 and over is Medicaid.1 In 

2011, 14 percent of people age 65 and over (6 million 

people) were enrolled in both Medicare and Medicaid 

(CMS Medicare-Medicaid Coordination Office 2013). 

Individuals enrolled in both Medicare-Medicaid are 

more likely than Medicare-only enrollees to be frail, 

live with chronic conditions, and have functional and/or 

cognitive impairments (Young et al. 2013). As a result, 

Medicare-Medicaid enrollees tend to use more, and 

more costly, medical care.

There are two main pathways for people age 65 and over 

to become eligible for both Medicare and Medicaid—

living in poverty for an extended amount of time or 

becoming impoverished due to high medical expenses. 

Those in the first group typically become eligible for 

Medicaid based on income or disability status before they 

turn 65, and then later qualify for Medicare based on age. 

Those in the second group become eligible for Medicare 

when they turn 65, and then later become eligible for 

Medicaid as a result of becoming impoverished due to 

high medical expenses (De Nardi et al. 2011). The second 

group is of particular interest to the Administration on 

Aging, as there is potential to prevent slow declines in 

health and delay adults aged 60 and over from “spending 

down” their assets and becoming eligible for Medicaid. 

An important first step in learning whether communitybased long-term care can help prevent or delay adults 

aged 60 and over from “spending down” and becoming 

eligible for Medicaid, is to better understand the service 

utilization of those who might be at risk based on their 

health or socioeconomic status. Adults aged 60 and over 

who are frail, impoverished, and/or have serious health 

conditions and functional limitations are often the ones 

who are more likely to need institutional care. In fact, 

Title III of the OAA focuses on this vulnerable population in delivery of its programs and services through the 

Aging Services Network. Therefore, learning more about 

the characteristics of the “at-risk” Medicare-only population, and the types of community-based services they use, 

may inform future research that helps adults aged 60 and 

over remain independent and avoid unnecessary institutional care.

1 People who are eligible for both Medicare and Medicaid, 

Medicare-Medicaid enrollees, all qualify for full Medicare 

benefits but differ in the amount of Medicaid benefits they are 

eligible to receive. Full Medicare-Medicaid enrollees are beneficiaries who qualify for full benefits from Medicaid as well as from 

Medicare, while partial Medicare-Medicaid enrollees are beneficiaries who qualify to have Medicaid pay some of the expenses 

they incur under Medicare (Congressional Budget Office 2013).

Using data from the National Survey of Older American 

Act Participants (NSOAAP), the study population was 

assessed by analyzing responses from participants in 

five Title III programs2 about AoA services received. 

Then, within each program, the Medicare-Medicaid 

enrollee group was defined as respondents who reported 

receiving Medicaid. Medicare-only enrollees were then 

classified into two at-risk groups based on either income 

or health characteristics that may predispose them 

towards becoming Medicare-Medicaid enrollees. Since 

characteristics of service recipients vary by program, 

the composition of the at-risk groups also varies across 

programs. Because several different combinations of 

characteristics can result in Medicare-only OAA service 

recipients being more vulnerable to becoming MedicareMedicaid enrollees, we identified two subgroups of 

Medicare-only enrollees who, by virtue of selected 

characteristics, may be potential Medicare-Medicaid 

enrollees.

As mentioned earlier, Medicare-Medicaid enrollees 

differ from Medicare-only enrollees on a variety of 

factors including income, health status, and demographic 

characteristics. Medicare-Medicaid enrollees are more 

likely than Medicare-only enrollees to have low incomes, 

poor health status, be female, and live alone or in institutions (CMS Medicare-Medicaid Coordination Office 

2013; MedPAC 2013; Coughlin et al. 2012). Therefore, 

this brief uses two at-risk categorizations to compare 

service utilization of adults aged 60 and over who might 

be at risk of becoming Medicare-Medicaid enrollees. 

The income at-risk group consists of individuals with 

household incomes below the poverty threshold3 (i.e., 

those more likely to qualify for Medicaid). The health 

at-risk group includes those that have difficulties with 

two or more Activities of Daily Living (ADLs), or three 

or more chronic health conditions but no income restrictions. Within each of the OAA Title III programs, the 

Medicare-only group is separated into these two at-risk 

groups to assess how these different dimensions or attributes may contribute to the type and mix of program and 

service use among OAA recipients.4

2 The five Title III programs were case management, homemaker, 

transportation, and congregate and home-delivered nutrition 

services.

3 While the federal poverty guidelines for 2012 were $11,170 for a 

single person household and $15,130 for a two-person household, 

we used $15,000 as our income maximum based on available 

income categories in the 2012 NSOAAP.

4 Note that the two at-risk groups are not mutually exclusive. Each 

group includes everyone who meets the criteria for being in that 

particular group.
3

Figure 1. Proportion of OAA Recipients by Risk Group and 

Service Utilization, 2012

0 25 50 75 100

Transportation

Services

(N=226,750)

Congregate

Nutrition Services

(N=1,645,051)

Homemaker

Services

(N=141,796)

Home-Delivered

Nutrition Services

(N=846,576)

Case

Management

Services

(N=427,580) 34

36

38

28

40

31

18

53

47

16

31

13

26

44

19

Medicare-Medicaid Enrollees*

Income At-Risk

Health At-Risk

Source: Seventh National Survey of OAA Participants (2012).

*In the NSOAAP, respondents are asked if they receive Medicaid 

benefits. They are not asked if they receive Medicare benefits. 

Since nearly all Americans age 65 and over have Medicare as the 

primary source of health insurance coverage, we made the assumption that anyone age 65 and over who reports receiving Medicaid is 

a Medicare-Medicaid enrollee. Among the population ages 60–64, 

data from the U.S. Census Bureau tells us that only 3 percent (or 

slightly more than 400,000) are enrolled in both Medicare and 

Medicaid. The data in this report have been adjusted to reflect these 

estimates. (Source: AGID, Data Files, AoA Special Tabulations, 

http://www.agid.acl.gov/DataFiles/ACS2011DIS/?stateabbr=AL,

2009–2011 ACS Special Tabulation, Disability Tables, 

http://www.agid.acl.gov/DataFiles/ACS2011DIS/Table/?tableid=S

210DIS10&state=AL, S210DIS10 - Health Insurance by Disability, 

accessed on September 19, 2014.)

Who Is At Risk?

When comparing Medicare-Medicaid enrollees to 

Medicare-only enrollees across the different programs, 

in general, a disproportionate share of MedicareMedicaid enrollees lack a high school diploma, are 

African American, and tend to report being in poor or 

fair health compared to Medicare-only enrollees (data 

not shown). However, while Medicare-only enrollees 

generally report better outcomes on certain health or 

socio-demographic dimensions when compared to 

Medicare-Medicaid enrollees, within the Medicare-only 

enrollees group, there is considerable heterogeneity in 

characteristics such as age, health status, and living 

arrangements.

When being at risk is defined by low income, the 

proportion of those at risk by each service type ranges 

from 31 percent among those receiving congregate 

nutrition services to 53 percent among those receiving 

homemaker services. In contrast, when defined by 

health status, the proportion of those at risk ranges from 

13 percent among those receiving congregate nutrition 

services, to 47 percent among those receiving homemaker services (Figure 1).

Across all service types, recipients of homemaker 

services have the largest proportion of participants at risk 

due to income or health, while the lowest proportion of 

those at risk appears to be among recipients of congregate nutrition services. The variation in the proportion 

of at-risk OAA clients by service type could be due to 

the specific needs of the clients or it could be due to 

heterogeneity of the population. However, the transitions 

between the at-risk and Medicare-Medicaid enrollees 

categories within any of the programs are unknown due 

to the limitations of a point-in-time study.

With the exception of congregate nutrition services 

participants classified as income at-risk, over one 

quarter of Title III program participants in each of 

the two at-risk groups reported receiving multiple 

services (Figure 2). A considerably higher proportion 

of case management and homemaker service recipients reported receiving multiple services compared to 

participants receiving home-delivered nutrition services, 

congregate nutrition services, or transportation services. 

The proportion of those receiving multiple services 

ranged from a low of 15 percent (congregate nutrition 

services—income at-risk) to a high of 68 percent (case 

management—health at-risk). In general, regardless 

of service type, health at-risk participants were more 

likely to receive multiple services compared to income 
4

Figure 2. Proportion of OAA Recipients Receiving Main 

Service Plus Two Additional Services by Risk Group and 

Main Service Utilization, 2012

0 25 50 75 100

Congregate

Nutrition Services

Transportation

Services

Homemaker

Services

Home-Delivered

Nutrition Services

Case

Management

Services 68

62

34

36

55

57

26

41

15

32

Income At-Risk Health At-Risk

Source: Seventh National Survey of OAA Participants (2012).

at-risk participants. This is likely due to health at-risk

individuals having multiple functional impairments, 

such as difficulties with two or more ADLs or three or 

more chronic conditions, and therefore needing a wider 

array of OAA services to remain in their homes. 

Receipt of Non-Title III Services Varies 

by Program and Risk Group

Medicare-Medicaid enrollees are a diverse population 

on a number of indicators (Coughlin et al. 2012). Yet 

most Medicare-Medicaid enrollees are living at or 

below the poverty level and are likely to be eligible for 

other federally funded services such as Supplemental 

Nutrition Assistance Program (SNAP), energy assistance, and/or housing subsidies.5

 To better understand 

if the at-risk measures in this brief are capturing those 

who are truly at risk of becoming Medicare-Medicaid 

enrollees, their participation in these federally funded 

services is examined. Across the various programs, 

5 The NSOAAP asks “Are you receiving any other types of assistance such as food stamps?” In 2008, the Food Stamp Act and 

Program was renamed the Supplemental Nutrition Assistance 

Program (SNAP).

Figure 3. Proportion of OAA Recipients Receiving SNAP, 

Energy, or Housing Assistance by Risk Group and Service 

Utilization, 2012

0 25 50 75 100

32

40

28

25

47

37

34

29

26

29

Congregate

Nutrition Services

Transportation

Services

Homemaker

Services

Home-Delivered

Nutrition Services

Case

Management

Services

Income At-Risk Health At-Risk

Source: Seventh National Survey of OAA Participants (2012).

a greater proportion of income at-risk participants 

reported receiving SNAP, energy, or housing assistance 

compared to health at-risk participants. The only 

exception was for congregate nutrition services where 

a greater proportion of health at-risk participants 

reported receiving these other federally funded services. 

The proportion of income at-risk participants receiving 

SNAP, energy, or housing assistance ranged from 26 

percent (congregate nutrition services) to 47 percent 

(homemaker services), while the proportion of health 

at-risk participants receiving these services ranged 

from 25 percent (home-delivered nutrition services) to 

37 percent (homemaker services) (Figure 3).

Do Services Help Those At Risk 

Stay in the Community?

The use of Title III services helps adults aged 60 and 

over live independently and remain in their homes and 

communities. More than 70 percent of those receiving 

case management, home-delivered nutrition, homemaker, transportation, or congregate nutrition services 

reported that this assistance allowed them to live independently (Figure 4).
5

Figure 4. Proportion of OAA Recipients Reporting that 

Services Allow Them To Live Independently by Risk 

Group and Service Utilization

0 25 50 75 100

Congregate

Nutrition Services

Transportation

Services

Homemaker

Services

Home-Delivered

Nutrition Services

Case

Management

Services

Income At-Risk Health At-Risk

77

91

86

72

90

79

89

84

84

72

Across all services, a greater proportion of income 

at-risk participants reported that these services 

enabled them to live independently compared to health 

at-risk participants. The proportion of income at-risk

participants reporting that these services enabled 

them to live independently ranged from 84 percent 

(congregate nutrition services) to 91 percent (case 

management services), while the proportion of health 

at-risk participants reporting the same ranged from 72 

percent (home-delivered nutrition services and congregate nutrition services) to 84 percent (transportation 

services).

Possible Implications

The cost of providing health care to Medicare-Medicaid 

enrollees is high and the number of people eligible for 

both programs continues to grow. Between 2006 and 

2011 the number of Medicare-Medicaid enrollees age 

65 and over increased by 12.5 percent from 5.3 million 

to 6.0 million (CMS Medicare-Medicaid Coordination 

Office 2013). The federal and state outlays to pay for the 

care of this population topped $319 billion in 2011 (Feder 

Source: Seventh National Survey of OAA Participants (2012).

et al. 2011).6 Because many older Medicare-Medicaid 

enrollees are more likely than Medicare-only enrollees 

to have a Medicare-qualifying disability (CMS 2013), be 

in fair or poor health, and have mental health needs (KFF 

May 2011), they are also more likely to need institutional 

care. Home and community-based services are intended 

to allow many adults aged 60 and over with disabilities 

to remain independently in the community and delay or 

eliminate the need for institutional care. 

While informative, this brief provides only a limited 

look at OAA recipients who are at risk of becoming 

eligible for Medicaid. Program recipients vary in their 

risk profiles and using other ways to assess risk would 

likely produce different results. However, Title III of the 

OAA targets its services to the most vulnerable adults 

aged 60 and over, those in greatest social and economic 

need. Therefore, many of the people receiving services 

through the Aging Services Network could be at risk 

for becoming eligible for Medicaid. For example, this 

analysis of OAA recipients has found that indicators 

of vulnerability include low income, poor health, and 

having limitations in functional status. OAA recipients with these characteristics exist in each population 

receiving services from Title III programs. Findings here 

suggest that it is the combination of these characteristics that play a role in determining who is vulnerable to 

becoming eligible for Medicaid. 

Given the heterogeneity of the Medicare-only population, using any single approach to targeting services 

may be infeasible. By exploring the different pathways 

to becoming at risk for Medicare-Medicaid eligibility, and examining service utilization among these 

different vulnerable subgroups, it may be possible 

to target the different subgroups with the particular 

services they need. While a comprehensive analysis is 

beyond the scope of this brief, future research could 

explore methods to construct a more multi-dimensional 

measure of risk that would account for combinations of 

risk factors.

Acknowledgments

We would like to thank the Office of Performance and 

Evaluation, Center for Disability and Aging Policy, 

Administration for Community Living for their guidance and feedback while completing this research brief.

6 This total includes a combination of federal spending ($175.7 

billion from Medicare and $80.9 billion from Medicaid) and state 

spending ($62.7 billion from Medicaid) for Medicare-Medicaid 

enrollees of all ages (Feder et al. 2011).
6

References

Centers for Medicare and Medicaid Services (CMS) 

Medicare-Medicaid Coordination Office. “Data 

Analysis Brief: Medicare-Medicaid Dual Enrollment 

from 2006–2011.” February 2013.

Congressional Budget Office. “Dual-Eligible 

Beneficiaries of Medicare and Medicaid: Characteristics, 

Health Care Spending and Evolving Policies.” 2013.

Coughlin, Teresa A., Timothy Waidmann, Lokendra 

Phadera, Rachel Garfield, and Barbara Lyons. 

“The Diversity of Dual Eligible Beneficiaries: 

An Examination of Services and Spending for 

People Eligible for Both Medicaid and Medicare.” 

Kaiser Commission on Medicaid and the Uninsured. 

Issue Paper. April 2012.

De Nardi, Mariacristina, Eric French, John Bailey Jones, 

and Angshuman Gooptu. “Medicaid and the Elderly.” 

NBER Working Paper No. 17689, 2011.

DeNavas-Walt, Carmen, Bernadette D. Proctor, 

and Jessica C. Smith, U.S. Census Bureau, Current 

Population Reports, p60–245 “Income, Poverty, and 

Health Insurance Coverage in the United States: 2012,” 

U.S. Government Printing Office. Washington, DC.

Feder, Judy, Lisa Clemans-Cope, Teresa Coughlin, 

John Holahan, and Timothy Waidmann. “Refocusing 

Responsibility for Dual Eligibles: Why Medicare 

Should Take the Lead.” Robert Wood Johnson 

Foundation, October 2011.

Federal Interagency Forum on Aging-Related Statistics. 

“Older Americans 2012: Key Indicators of Well-Being.” 

Washington, DC: U.S. Government Printing Office. 

June 2012.

Kaiser Family Foundation. Kaiser Commission on 

Medicaid Facts. Medicaid and the Uninsured. “Dual 

Eligibles: Medicaid’s Role for Low-Income Medicare 

Beneficiaries.” May 2011.

Medicare Payment Advisory Commission (MedPAC). 

“A Data Book: Health Care Spending and the Medicare 

Program. Section 3: Dual Eligible Beneficiaries.” June 

2013.

Young, Katherine, Rachel Garfield, MaryBeth 

Musumeci, Lisa Clemans-Cope, and Emily Lawton. 

“Medicaid’s Role for Dual Eligible Beneficiaries. The 

Kaiser Commission on Medicaid and the Uninsured.” 

Issue Brief. August 2013.

Data

Information on Title III participants was drawn from 

the Seventh National Survey of OAA Participants. 

Westat, Inc., conducted the telephone survey in 2012, 

administering it to over 5,000 people who reported 

receiving Title III services. This brief includes data for 

4,158 recipients who were surveyed about their experiences with case management, home-delivered nutrition 

services, homemaker services, congregate nutrition 

services, and transportation services. The survey used 

a two-stage sample design, first selecting a sample of 

AAAs and then randomly sampling participants from 

each selected AAA by service type. The number of 

participants selected from each AAA was proportional 

to the number of participants served in that particular 

service by the sampled AAA. All analyses in this 

brief apply sample weights to account for this design. 

Additional data from, and more detailed documentation 

about, the NSOAAP and other AoA data sources are 

available on the AGing Interactive Database (AGID) 

located at http://www.agid.acl.gov.

This series is funded by AoA, and presents analyses conducted by Social & Scientific Systems 

using data from AoA’s National Survey of Older 

Americans Act Participants. This survey collects 

information from Title III recipients about their 

demographics, socioeconomic status, health, 

and functioning, as well as their service use and 

client-reported service impact and quality. For 

more information about this study, please contact 

Niranjana Kowlessar at Social & Scientific Systems, 

NKowlessar@s-3.com.

About This Series