Navigating Health Systems to Find Her Own Independence: Maria’s Story

Meet Maria

As someone with complex health conditions, Maria credits the benefits she receives through her dual eligibility for Medicare and Medicaid for her personal independence. But those benefits didn’t come easily.  

Navigating two health care systems and finding the right health care plan took more than three months of phone calls, dead end leads, and countless denials. 

Since moving from Ohio to Orlando three years ago, Maria struggled to find the right health care plan—one that integrates her Medicare and Medicaid benefits and covers the services and urological supplies she needs to stay healthy. After trying three different Medicare Advantage plans, a local organization, SHIP (State Health Insurance Assistance Program), helped her find a Medicare Advantage plan that covers all of her specialists and her medical equipment. 

With a Little Help, and a Lot of Work 

Even with the connections made through SHIP and endless internet research, Maria still found herself struggling to find a plan that would work for her unique needs.  

Maria isn’t alone: these recurring issues create unnecessary stress and barriers to the care many people in this country need. Some 12 million people are eligible for both Medicaid and Medicare — sometimes referred to as “dually eligible individuals.”  Dually eligible people face significant, complex and/or chronic health challenges that require ongoing care. Many are older adults and people with disabilities who live on low, fixed incomes, manage multiple chronic conditions like diabetes and heart disease, and have a critical need for services like assistance with daily living activities like getting dressed, bathing, or eating; they often have a greater need for services such as inpatient and outpatient hospital, emergency room, and skilled nursing care. Despite having serious and complex health needs, dually eligible people often face a complex web of health care systems that are difficult to navigate, leading to uncoordinated coverage, higher health system costs, and worse health outcomes. 

Dually eligible people are often faced with an overwhelming number of enrollment options. Locating and accessing support systems that have the knowledge about both programs to provide neutral and clear guidance can be difficult — people may not know where to turn or even that these services are available to them. Too often this results in people being left to navigate a sea of websites and disjointed systems alone and they end up on health care plans that don’t fully meet their needs. 

This is a reality Maria knows all too well.  

What should be ready access to medical care has become an ongoing battle to become the self-advocate for the care she needs. “It’s like a full-time job,” she shares.  

A Path Towards Simpler Coverage

Everyone deserves to live the life they want and to have the coverage and care they need to do so. For dually eligible individuals, finding the right plan is critical to being able to manage their serious and complex health conditions and live the life they want. Inadequate coverage can lead to delayed care, putting their health, wellbeing and livelihood on the line.  

With the right policies in place, we can ensure dually eligible people are able to access the information and supports they need to select a coverage plan that fully meets their health needs. Additional investments are needed to ensure dually eligible people are supported to understand the different plans, benefits available, and how to effectively access them to get the care they need.

This looks like: 

• Providing additional investments to existing trusted organizations and community-based organizations that are already meeting dually eligible people where they are at—helping dually eligible people access and navigate local resources. 
• Bolstering supports that are already working to provide communities with neutral and accessible enrollment information unaffiliated with any particular health plan, such as Medicare State Health Insurance Assistance Programs and Medicaid Navigators 

If you or someone you love relies on Medicaid and Medicare, your voice can make a difference.  

Record a short video sharing how these changes could affect your life—whether you’re a caregiver, an older adult, someone with a disability, or just trying to stay healthy and housed.

Your story will show policymakers what’s really at stake and can help us demand better.