Medicare Advantage Coverage Among Individuals Receiving Federal Housing Assistance

A recent study commissioned by the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation (ASPE) and HUD’s Office of Policy Development and Research (PD&R) examined the prevalence of Medicare Advantage (MA) coverage among individuals who also receive federal housing assistance (hereinafter referred to as HUD-MA individuals). Individuals enrolled in MA plans are Medicare eligible (generally, people ages 65 and older or, in certain cases, people younger than 65 with a disability or certain chronic conditions) and choose to cover their Medicare benefits (such as hospital stays and doctor’s visits) with MA plans, which are offered through private insurance companies, rather than a traditional fee-for-service arrangement (that is, Original Medicare).

Understanding MA coverage among older adults receiving federal housing assistance is important because this population faces disproportionately high rates of chronic conditions and healthcare utilization. Coordinated services may help meet the needs of this population and allow them to continue living independently as they age. HUD-MA individuals potentially could benefit from the care coordination and nonmedical benefits that private MA health insurance plans offer.

Released in April 2024,“Medicare Advantage Coverage Among Individuals Receiving Federal Housing Assistance” presents demographic characteristics and geographic concentrations of individuals enrolled in MA health insurance plans and participating in HUD’s rental assistance housing programs.

The study determined that, compared with individuals enrolled in traditional Medicare plans, HUD-MA individuals were more likely to have lower incomes, belong to a racial or ethnic minority group, and demonstrate dual eligibility for Medicaid. This study sheds light on the potential for providing coordinated services to HUD-MA enrollees, who face disproportionately higher rates of adverse health outcomes compared with their peers enrolled in Medicare and MA without HUD assistance.

Research Methods

Under a contract with ASPE and PD&R, The Lewin Group linked HUD administrative records with Centers for Medicare and Medicaid Services (CMS) Medicare enrollment and MA plan data from 2018 to 2020. Specifically, the research team merged person-level HUD longitudinal data with CMS Master Beneficiary Summary File data. Researchers matched individual Social Security numbers and enrollment years across the datasets to obtain information pertaining to HUD program category; MA coverage; demographics, including age, race, ethnicity, gender, head of household status, household size, and income; and geographic area, including city, county, state, and metropolitan statistical area. In addition, the merged data contained HUD property identifiers to enable researchers to identify HUD-MA individuals residing in HUD-assisted properties.

The study population included all HUD-assisted individuals with MA coverage for at least 1 month during the study period. The research team estimated MA enrollment among HUD-assisted individuals in each calendar year during the study period and analyzed (1) the type and ownership of MA plans in which this population was enrolled, (2) HUD programs through which this population received assistance, and (3) the demographic composition and geographic distribution of this population.

Major Findings

During the study period, the annual number of HUD-assisted individuals with MA coverage increased. Across all 3 study years, 11.6 million individuals received HUD housing assistance, of whom 2.9 million (25%) were enrolled in Medicare. Among HUD-assisted individuals with Medicare coverage, 1.5 million (approximately 50%) were enrolled in MA plans. Between 2018 to 2020, the annual number of HUD-MA individuals rose from approximately 1 million to 1.2 million, an increase of approximately 19 percent. Over that same period, the annual number of HUD-assisted individuals declined by 2 percent. The annual number of HUD-MA individuals who are ages 65 and older increased from approximately 720,000 in 2018 to 854,000 in 2020.

Compared with the overall population of people who received federal housing assistance, greater proportions of those receiving federal housing assistance and enrolled in MA plans in 2020 were ages 65 and older, earned an annual household income of less than $25,000, and identified as female or Hispanic, and a smaller proportion identified as a person of color. Fifty-six percent of HUD-MA individuals had a HUD-qualifying disability, such as a physical, mental, or emotional impairment. In addition, slightly more than 60 percent of HUD-MA individuals were dually enrolled in Medicaid.

Out of 1.2 million HUD-MA individuals in 2020, approximately 42 percent received voucher-based housing assistance, including tenant-based housing choice vouchers and project-based Moving to Work vouchers. The proportion of HUD-MA households receiving vouchers exceeded the proportions of those receiving other forms of HUD program assistance, including project-based Section 8 (32%), public housing (19%), Section 202 Supportive Housing for the Elderly (6%), and Section 811 Supportive Housing for Persons with Disabilities (0.6%). Very little change was evident in the proportion of HUD-MA individuals receiving assistance from each type of HUD program during the study period.

In 2020, roughly 40 percent of HUD-MA individuals were enrolled in MA plans offered through UnitedHealth Group and Humana, and smaller shares of HUD-MA individuals were enrolled in plans offered by other insurance companies, such as Anthem, Centene, Healthfirst, and Aetna/CVS Health Corporation.

In 2020, 41 percent of HUD-MA individuals resided in five states: New York, California, Florida, Texas, and Pennsylvania. Nearly 90 percent of HUD-assisted properties had at least one individual enrolled in MA residing at the property, and 54 percent (16,249 properties) had more than 10 individuals enrolled in MA. California, New York, and Pennsylvania had the most HUD-assisted properties where at least one MA enrollee resided, with 1,819, 1,643, and 1,486 properties, respectively. These states also had the largest number of HUD-assisted properties in which more than 10 MA enrollees resided.

Policy Implications

Researchers determined that, compared with their overall Medicare and MA counterparts, HUD-MA individuals tend to be more likely to earn lower incomes, belong to a racial or ethnic minority group, and demonstrate dual eligibility for Medicaid — attributes that are correlated with an increased risk of adverse health outcomes. Such groups tend to face more chronic health challenges and use healthcare systems more frequently than their peers who are not HUD assisted.

To overcome these barriers, the researchers emphasize strengthening partnerships among MA health insurance plans and their parent companies and public health officials, public housing agencies, and HUD-assisted property managers. Targeting care coordination and supportive services to the geographic locations with high concentrations of HUD-MA enrollees may be a viable opportunity to help improve long-term health outcomes, especially among older adults who wish to age in place. Place-based interventions could provide tailored assistance to meet enrollees’ needs based on resources available in their jurisdictions. Health officials in these areas can examine housing-with-services models, such as the Support and Services at Home program, which operates in Vermont, or the Integrated Wellness in Supportive Housing model, as best practices for coordinating care. Increased collaboration will be critical going forward to assess long-term services and support and social needs among HUD-MA individuals over time and tailor interventions to effectively meet their needs.