Medicare Advantage Coverage Among Individuals

Receiving Federal Housing Assistance

Geographic concentrations of Medicare Advantage enrollees who receive federal

housing assistance present opportunities to facilitate delivery of care coordination and supportive services for a population at higher risk for adverse health outcomes.

Soumita Lahiri, Lisa Alecxih, Preston Havens, Tazuko Ricento, and Daniel Gregory

KEY POINTS

• This study examined Medicare Advantage (MA) enrollment among individuals receiving U.S.

Department of Housing and Urban Development (HUD) housing assistance, as well as the demographic composition and geographic distribution of this population. Analyses were conducted using analytic data created by linking HUD administrative data to Centers for Medicare

& Medicaid Services Medicare enrollment and MA plan data for three years (calendar years [CY]

2018–2020). This report summarizes key findings. *

• Across all three years (2018–2020), approximately 11.6 million individuals received federal housing assistance. Approximately 2.9 million of those individuals (25%) had Medicare coverage and, among those with Medicare coverage, approximately 1.5 million (51%) had Medicare Advantage coverage.

• Between 2018 and 2020, the annual number of both HUD-assisted individuals overall and HUD-assisted individuals with Medicare coverage declined (from ~9.5 million to ~9.3 million and from

~2.6 million to ~2.5 million, respectively), whereas the annual number of HUD-assisted individuals with Medicare Advantage coverage increased (from ~1 million to ~ 1.2 million). The annual number of HUD-assisted individuals ages 65 and older with Medicare Advantage coverage increased from approximately 720,000 to 854,000.

• Compared with the overall Medicare and MA populations, individuals enrolled in MA who were receiving federal housing assistance were more likely to have lower incomes, be dually eligible for Medicaid, and identify as a person of color. In prior published studies, these same characteristics have been associated with greater risk of adverse health outcomes.

_______________________

* The Department of Housing and Urban Development will host an interactive web-based dashboard supplementing this report. The dashboard will be available on the study website page on HUDUser.gov.

• In 2020, among individuals receiving federal housing assistance with MA coverage: o Approximately two-thirds were enrolled in plans offered by five MA plan parent organizations (29% were covered by UnitedHealth Group, 13% by Humana, 8% by Anthem, 8% by Centene, and 5% by Healthfirst);

o Sixty-two percent (~770,000 individuals) resided in project-based HUD-assisted properties (public housing or assisted multifamily housing); and

o Nearly one-third (~400,000 individuals) lived in project-based Section 8 buildings, 6% (~75,000) lived in Section 202 properties for older adults, and 0.6% (~8,000) lived in Section 811

properties for individuals with disabilities.

• In 2020, nearly 90% of HUD-assisted properties had at least one individual enrolled in MA, and 16,249 HUD-assisted properties (54%) had more than 10 individuals enrolled in MA. A subset of these properties (660) had more than 10 individuals enrolled in the same MA plan. †

• In 2020, approximately 40% of individuals receiving federal housing assistance with MA coverage lived in five states (New York, California, Florida, Texas, and Pennsylvania). Nationwide, approximately one-third lived in a metropolitan statistical area.

• MA plans could explore partnering with public health and housing entities to identify geographic concentrations of MA enrollees receiving federal assistance, analyze their health plan data, assess their social needs, and offer place-based interventions.

_______________________

† Note: Disclosure requirements established the minimum reporting threshold of greater than 10 used in this report and the interactive tool.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

2

INTRODUCTION

The U.S. Department of Housing and Urban Development (HUD) oversees rental assistance programs that help more than nine million low-income individuals live in safe, decent, and affordable homes. 1 Prior research from the Department of Health and Human Services’ (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) and HUD’s Office of Policy Development and Research (PD&R) found certain groups of individuals receiving federal housing assistance (referred to as HUD-assisted individuals in this report)‡ had more chronic conditions and greater health care utilization than individuals not receiving federal housing assistance. 2,3 Coordinated delivery of health care and supportive services may help meet the needs of HUD-assisted individuals and allow them to remain in an independent living setting, even as they age or their health worsens. HUD-assisted individuals with Medicare Advantage (MA) coverage could potentially benefit from the care coordination and supplemental benefits offered by MA plans.

ASPE and PD&R contracted with The Lewin Group to analyze MA plan enrollment among HUD-assisted individuals. Using HUD administrative data linked to Centers for Medicare & Medicaid Services (CMS) Medicare enrollment and MA plan data, this study examined the demographic composition, geographic distribution, and MA enrollment characteristics of, as well as the type of HUD assistance received by, this population.

This report presents a summary of the findings and is organized into six sections: Background, Methods, Findings, Discussion, Conclusion, and Appendices. In addition to this report, geographic concentrations (e.g., by state, county, and HUD-assisted property) of MA-HUD individuals can be identified through an interactive web-based dashboard that is forthcoming.

_______________________

‡ Terminology used throughout this report: (1) “HUD-assisted” refers to individuals receiving federal housing assistance, (2) “HUD-Medicare” refers to HUD-assisted individuals enrolled in Medicare, and (3) “HUD-MA” refers to HUD-assisted individuals enrolled in a MA plan.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

3

BACKGROUND

HUD Assistance Programs

HUD provides rental assistance through a variety of program categories, § the largest of which are (1) housing choice vouchers; (2) public housing; and (3) assisted multifamily. Public housing and assisted multifamily programs offer project/property-based assistance, and housing choice vouchers may be used to rent privately owned housing. Table 1 summarizes the features of these program categories.

Table 1. Types of HUD Housing Assistance

Housing Choice Vouchers (HCV)**

Public Housing (PH)††

Assisted Multifamily (MF)‡‡

Individuals may use vouchers to pay for

Affordable rental housing for low-

Privately owned subsidized housing for

all or part of the rent for properties of

income families, older people, and

which the federal government enters

their choice

people with disabilities

into a contractual agreement with

owners to ensure reduced rents for

low-income tenants

• Tenant-based

• Project-based

• Project-based

• HUD’s largest rental assistance

• Mostly multifamily

• Consists of multiple programs,

program

• Federally funded and regulated

including Project-Based Section 8

• Monthly rental assistance payment

• Managed by local entities (public

(PBS8) and smaller specialized

allows families to rent privately

housing authorities or agencies

programs, such as Section 811 for

owned housing

[PHAs])

individuals with disabilities and

• Administered by PHA

Section 202 for older adults

• PHA wait list preferences apply

• PHA wait list preferences apply

(e.g., people experiencing

• HUD contracts with the owner of the

(e.g., people experiencing

homelessness)

development

homelessness)

• If tenant moves, assistance stays

with the owner

Source: https://www.huduser.gov/portal/datasets/assthsg.html.

HUD-Assisted Individuals' Health Status and Health Care Utilization

HUD-assisted individuals differ from unassisted populations across a variety of health and health care utilization measures. For example, greater percentages of HUD-assisted adults reported having fair or poor health and a higher prevalence of 10 health conditions (including hypertension, chronic obstructive pulmonary disease [COPD], and cancer) and disability compared with low-income renters not receiving federal housing assistance and the general adult population. 4 In addition, compared with low-income renters and the general adult population, a larger percentage of HUD-assisted adults reported one or more emergency room visits in the past 12 months. 5 Two prior studies from ASPE, PD&R, and the Lewin Group found differences in health and health care utilization between traditional fee-for-service (FFS) Medicare§§ enrollees ages 65 and older who received HUD assistance and those who did not receive HUD assistance in 12 geographic areas. 6, 7 Compared with unassisted Medicare enrollees, a greater percentage of HUD-assisted Medicare enrollees had five or more chronic conditions (38% compared with 33%). 8 A larger difference was observed between HUD-assisted and _______________________

§ Refer to PD&R’s Assisted Housing: National and Local for descriptions: https://www.huduser.gov/portal/datasets/assthsg.html.

** Refer to the HUD’s Housing Choice Vouchers Fact Sheet for additional information:

https://www.hud.gov/topics/housing_choice_voucher_program_section_8.

†† Refer to HUD’s Public Housing Program webpage for additional information: https://www.hud.gov/topics/rental_assistance/phprog.

‡‡ Refer to HUD’s Section 8 Program Background Information webpage for additional information:

https://www.hud.gov/program_offices/housing/mfh/rfp/s8bkinfo.

§§ Medicare is a federal health insurance program for individuals ages 65 and older and some people younger than 65 with certain disabilities or conditions.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

4

unassisted individuals dually enrolled in Medicare and Medicaid, *** with 55% of HUD-assisted individuals having five or more chronic conditions compared with 43% of unassisted individuals. 9 After controlling for confounding factors (for example, race, ethnicity, age, geography, count of chronic conditions, and supply of health care providers in the market), HUD-assisted Medicare enrollees were more likely than unassisted Medicare enrollees to have an acute inpatient stay, a Medicare-covered nursing home stay, and emergency department visits than those who did not receive federal housing assistance. 10 However, among older adults dually enrolled in Medicare and Medicaid, HUD-assisted individuals were less likely than unassisted individuals to have any acute inpatient stay or a Medicare-covered nursing home stay, whereas differences in the likelihood of an emergency department visit varied by geographic region. 11 Among individuals dually enrolled in Medicare and Medicaid, HUD-assisted individuals had lower Medicare expenditures compared with unassisted individuals, whereas there was no significant difference in Medicare expenditures for HUD-assisted and unassisted individuals enrolled in only Medicare. 12

On average, HUD-assisted individuals have higher rates of characteristics that prior research has found to be associated with an increased likelihood of experiencing adverse health outcomes and greater health care utilization. For example, in 2021, compared with all community-dwelling individuals, a higher proportion of HUD-assisted individuals had annual household income less than $20,000 (77% compared with 14%), were age 62 or older (39% compared with 21%), and identified as Black, Native American, Asian, Pacific Islander, or Hispanic (66% compared with 41%). ††† Unmet social needs, environmental factors, and barriers to accessing health care contribute to adverse health outcomes for people with lower incomes. 13 Across the lifespan, residents of impoverished communities face an increased risk of mental illness, chronic disease, and death. 14,

15, 16 Compared with younger adults, older adults (those ages 65 and older) have a higher prevalence of multiple chronic conditions, and health care utilization and spending are higher for people with more chronic conditions. 17 Racial and ethnic disparities in health care utilization also exist. For example, Black Medicare enrollees were more likely to have an inpatient hospital stay or emergency room visit. 18 In addition, HUD-assisted adults were more likely than both the general adult population and low-income renters not receiving federal housing assistance to have a disability. 19 When compared to individuals without disabilities, individuals with disabilities typically experience significant health disparities, such as worse perceived health status and greater prevalence of chronic conditions, and face greater barriers to accessing health care services. 20

Care Coordination and Supportive Services

Coordination of health care and delivery of supportive services may help meet the needs of HUD-assisted individuals and allow them to remain in independent living settings, even as they age or their health worsens.

Affordable housing sites offer existing infrastructure to support the provision of care coordination and long-term services and supports to older adults and individuals with disabilities. Housing-with-services models offer affordable housing coupled with care coordination and supportive services. These models vary in the mix of services provided, flexibility of service delivery, type of housing, and whether they are project-based or tenant-based. 21 An evaluation of the Support and Services at Home (SASH) program, a housing-with-services model targeting older adults in affordable housing sites in Vermont found that the model improved medication _______________________

*** Medicaid, a joint federal and state health insurance program, provides coverage to some people with limited income and resources; eligibility and covered services vary by state.

††† HUD-assisted data come from the 2021 Summary of All HUD Programs, available at

https://www.huduser.gov/portal/datasets/assthsg.html#2009-2021_data; U.S. community residents and household data come from the 2021 American Community Survey, available at https://data.census.gov/all?d=ACS%2B1-

Year%2BEstimates%2BDetailed%2BTables.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

5

management and reduced the growth in total Medicare expenditures. 22 HUD’s Integrated Wellness in Supportive Housing (IWISH) demonstration is testing a model similar to SASH in 40 sites across the country. ‡‡‡

Medicare Advantage Supplemental Benefits

HUD-assisted older adults and certain younger individuals with disabilities may be eligible for Medicare.

Medicare-eligible individuals have the option to receive Medicare coverage through traditional FFS Medicare or MA plans offered under Medicare Part C. MA plans receive a capitated monthly payment per enrollee to cover health care expenses incurred by enrollees. MA plans provide all Medicare Part A benefits (primarily inpatient and outpatient hospital visits along with short-term post-hospital skilled nursing facility care) and Part B benefits (primarily physician visits and laboratory services), and usually Part D (drug coverage), and may provide additional benefits beyond those covered under the traditional FFS Medicare program (lower cost sharing, lower beneficiary premiums, and/or supplemental benefits (e.g., vision, hearing, and dental), depending on the plan). 23 Over time, enrollment in MA plans has increased, with the percentage of Medicare-eligible individuals enrolled in MA plans growing from 28% in 2013 to 49% in 2023. 24, 25

In recent years, MA plans have been able to offer a broader scope of supplemental benefits to enrollees and to target offered benefits to members by health status or disease state. Beginning in 2019, CMS expanded the definition of “primarily health-related” supplemental health care benefit to allow MA plans to offer in-home support services. 26 In addition, since 2020, MA plans have been able to offer Special Supplemental Benefits for the Chronically Ill (SSBCI), which are supplemental benefits available to eligible chronically ill members, as required by statute. 27 In 2022, more than 1,800 MA plans (approximately one-third of all MA plans) offered expanded primarily health-related supplemental benefits and/or SSBCI. 28 Additionally, MA plans participating in CMS Innovation Center’s Value-Based Insurance Design Model can offer supplemental benefits. 29

HUD-assisted individuals with MA coverage, particularly those residing in HUD-assisted properties, may benefit from these supplemental benefits that can help address long-term services and supports needs (e.g., support with activities of daily living). As with housing-with-services models, MA plans and their parent organizations may be able to take advantage of the infrastructure provided by properties receiving HUD assistance (referred to as HUD-assisted properties) to deliver care coordination and supportive services to older adults and individuals with disabilities who are enrolled in their plans. MA plans and their parent organizations may realize efficiencies in care coordination and supportive service delivery if they have members residing in the same location, such as a HUD-assisted property.

_______________________

‡‡‡ Evaluation findings from the first three years of the demonstration available at

huduser.gov/portal/sites/default/files/pdf/IWISH_FirstInterimReport.pdf.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

6

METHODS

To determine MA penetration among HUD-assisted individuals, we deterministically linked HUD administrative data and CMS Medicare enrollment data from 2018 to 2020 (Figure 1). Specifically, we merged individual-level data on persons receiving federal housing assistance from HUD’s annual longitudinal file with Medicare enrollee data from the CMS Master Beneficiary Summary File (MBSF) using nine-digit Social Security numbers (SSNs). We also used MA plan data from the CMS Medicare Plan Characteristics File. The final dataset (Final Analytic Data) contained annual information on HUD program enrollment, demographic characteristics, geographic location, Medicare and MA plan enrollment, MA plan information, and Medicaid eligibility status for all HUD-assisted individuals with Medicare coverage. Refer to Appendix A for more information on data sources and the linkage methodology.

Figure 1. Data Sources and Development of the Analytical File

CMS = Centers for Medicare and Medicaid Services. HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage. MBSF = Master Beneficiary Summary File. SSN = Social Security number.

Notes: N = Total number of records representing individuals across the specified time frame (in millions). HUD captures information on individuals receiving housing assistance in two systems: the Tenant Rental Assistance Certification System (TRACS) and the Inventory Management System (IMS)/Public and Indian Housing (PIH) Information System (PIC). Longitudinal data compiles information captured in the TRACS and PIC into a unique dataset for each calendar year.

Sources: HUD longitudinal data and CMS Master Beneficiary Summary File merged records; Medicare enrollment based on Medicare enrollment charts available at https://www2.ccwdata.org/web/guest/medicare-charts/medicare-enrollment-charts.

The study population included all persons who received federal housing assistance in a given calendar year during the study period (2018–2020) and were enrolled in an MA plan for at least one month during that calendar year. Individuals may have been enrolled in an MA plan for multiple months during a calendar year or enrolled in multiple MA plans during a calendar year. Property-level analyses (e.g., count of HUD-assisted properties, count of individuals or MA plans in a property) were restricted to individuals who lived in a HUD-assisted property (primarily persons receiving public housing or assisted multifamily types of assistance). To meet disclosure requirements, select property-level analyses presented in this report and the associated April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

7

interactive web-based dashboard were further restricted to HUD-assisted properties with greater than 10

residents with MA coverage.

Using the final dataset, we estimated MA enrollment among HUD-assisted individuals in each calendar year during the study period and analyzed the type and ownership of MA plans in which this population was enrolled, HUD programs through which this population received assistance, and the demographic composition and geographic distribution of HUD-MA individuals. Key findings are presented in the body of this report; refer to Appendix B for detailed findings.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

8

FINDINGS

Between 2018 and 2020, 11.6 million individuals received federal housing assistance (Appendix B, Table B.1).

Among those HUD-assisted individuals, 2.9 million had Medicare (traditional or MA) coverage and 1.5 million were enrolled in MA. §§§ Annually, the total number of HUD-assisted individuals and HUD-assisted individuals covered by Medicare declined by 2% and 4%, respectively, between 2018 and 2020 (Table 2). However, during those same years, the number of HUD-assisted individuals enrolled in MA increased by nearly 200,000, an approximately 19% increase. Growth in MA enrollment among HUD-assisted individuals was greater than the approximately 13% growth in MA enrollment overall (Table 2).

Among adults ages 65 and older, the number receiving federal housing assistance increased by 5%, from 1.5

million to 1.6 million, between 2018 and 2020. During those same years, the number of HUD-assisted older adults enrolled in Medicare increased by 4% (from 1.48 to 1.53 million) and the number enrolled in MA increased by 19% (from approximately 720,000 to 854,000) (Appendix B, Table B.1).

In 2020, the most recent year for which data were available, 9.3 million individuals received federal housing assistance (Table 2). Twenty-six percent of HUD-assisted individuals (2.5 million) had Medicare coverage and 13% of HUD-assisted individuals (1.2 million) were enrolled in an MA plan. Ninety-six percent of HUD-assisted older adults had Medicare coverage and 54% were enrolled in an MA plan (Appendix B, Table B.2).

Table 2: Enrollment in Medicare and Receipt of Federal Housing Assistance (in Millions), 2018–2020

Enrollment Type

2018

2019

2020

Enrolled in Medicare

(traditional or

62.93

64.43

65.90

Medicare Advantage)

(throughout the year)

Enrolled in Medicare

Advantage (for full

30.75

32.57

34.71

year or partial year)

Receiving federal

housing assistance

9.51

9.42

9.32

With Medicare

coverage (HUD-

2.56

2.52

2.45

Medicare)

With Medicare

Advantage coverage

1.04

1.14

1.24

(HUD-MA)1

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: This table includes all individuals enrolled in MA for at least one month in a year and counts an individual only one time irrespective of number of plans. HUD-Medicare and HUD-MA individual counts based on matching SSN between HUD

longitudinal data and CMS MBSF data for the same calendar year.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Demographic Characteristics of HUD-MA Individuals

In 2020, relative to the total Medicare- and MA-enrolled populations, higher proportions of HUD-MA individuals identified as female or a person of color and lived on less than $25,000 annually (Figure 2).

Although the majority (69%) of HUD-MA individuals were ages 65 and older, the proportion of HUD-MA _______________________

§§§ Some individuals had different HUD and Medicare/MA benefit coverage time periods. For results provided by calendar year, only individuals receiving federal housing assistance and enrolled in MA in the same calendar year were included.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

9

individuals younger than age 65 (who likely qualified for Medicare due to disability) was twice that of all MA enrollees (31% versus 15%). HUD administrative data identified 56% of HUD-MA individuals who experienced some disability**** (Appendix B, Table B.4); however, this percentage is likely an underestimate of the prevalence of disabilities in this population. 30

Sixty-one percent of HUD-MA individuals also had full-benefit Medicaid coverage†††† (considered “dually eligible”) for the entire time they had MA coverage during the study period (Appendix B, Table B.9); among all MA enrollees, 12% had full-benefit Medicaid coverage (not shown). Full-benefit Medicaid coverage refers to coverage of a more extensive package of services (e.g., long-term services and supports and behavioral health, transportation, and vision services) than only coverage of Medicare premiums and cost-sharing available through Medicare Savings Programs.

Figure 2. Proportion of Individuals by Select Demographic Characteristics, 2020

100%

91%

85% 85%

80%

74%

80%

69%

69% 62%

64%

55% 56%

60%

38%

40%

31%

24%

29%

21%

17%

20%

20%

8% 12%

0%

Age 65+

Female

People of Color

Hispanic

Income <$25k

Medicare Enrollees

MA Enrollees

HUD-MA Individuals

HUD-assisted Individuals

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: In this report, the term “People of Color” includes individuals of all races and ethnicities (Black, Asian, American Indian, Native Hawaiian or Other Pacific Islander, multiple races), excluding White non-Hispanic. Hispanic refers to individuals indicating Hispanic ethnicity. Estimated percentage of HUD-MA individuals with less than $25,000 was calculated using HUD’s methodology for household income.

Sources: Medicare enrollee (includes both traditional and MA) and MA enrollee estimates are based on authors’ analysis of the 2021

Medicare Current Beneficiary Survey COVID-19 Winter Supplement Public Use File, available at https://www.cms.gov/Research-

Statistics-Data-and-Systems/Downloadable-Public-Use-Files/MCBS-Public-Use-File. HUD-assisted individual and HUD-MA individual estimates were calculated using the 2020 HUD longitudinal data and CMS Master Beneficiary Summary File merged data. The estimated percentage of HUD-assisted individuals with less than $25,000 in income was calculated using 2020 HUD

longitudinal, person-level file data available for internal HUD use only.

Duration of MA Enrollment Among HUD-assisted Individuals

In each year from 2018 through 2020, the majority of HUD-MA individuals had MA coverage for all 12 months in a given year and did not switch MA plans. More than 80% of HUD-MA individuals had MA coverage for all 12

_______________________

**** Disability is based on mbr_dsblty_indr field captured in HUD longitudinal data, which is not consistent with Supplemental Security Income, Social Security, or Medicaid disability definitions. Definitions to establish eligibility or obtain HUD program benefits as a person with disabilities vary by program. See Appendix B: Applicable Definition of Disability for Determining HUD Eligibility in A Primer on HUD Programs and Associated Administrative Data, available at https://www.cdc.gov/nchs/data/datalinkage/primer-on-

hud-programs.pdf.

†††† Medicaid, a joint federal and state program, provides health coverage to some people with limited income and resources; eligibility and covered services vary by state. Full Medicaid coverage was identified based on DUAL_ELGBL_CD in the CMS MBSF data. An individual was flagged to have full Medicaid coverage if the indicator had values 02, 04, or 08 and had a valid MA plan ID (non-missing) for the month.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

10

months in a given year. Approximately 90% were enrolled in a single MA plan over the course of a year (although they may have been enrolled for fewer than 12 months) (Table 3; Appendix B, Table B.7).

Among the approximately 1.5 million HUD-assisted individuals who were enrolled in an MA plan between 2018

and 2020, almost 810,000 individuals (54%) had MA coverage in all three years (Table 4). Among those with MA coverage for all three years, just over 612,000 (76%) were enrolled in the same plan for all three years.

Another almost 20% of HUD-MA individuals were enrolled in an MA plan for two consecutive years (85% of which had the same plan for both years). Individuals may have had MA coverage for fewer than three years during the study period for multiple reasons, including death or not qualifying for Medicare coverage.

Table 3. Duration of Medicare Advantage Enrollment During a Single Year Among HUD-assisted Individuals, 2018–2020

Enrollment

2018

2019

2020

Total enrolled in MA

1,043,670

1,143,943

1,243,128

Enrolled for part of the yeara

179,319

179,829

155,982

Enrolled for the full yearb

864,164

963,954

1,086,988

% Full year

82.8%

84.3%

87.5%

Multiple plans during the year

96,579

111,096

125,521

Single plan during the year

946,904

1,032,847

1,117,607

% Single plan

90.7%

90.3%

89.9%

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: (a) Includes individuals enrolled in an MA plan for fewer than 12 months in a calendar year; individuals may be enrolled in multiple MA plans during the year. (b) Includes individuals enrolled in an MA plan for all 12 months in a calendar year; individuals may be enrolled in multiple MA plans during the year.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Table 4. Duration of MA Enrollment During All Study Years Among HUD-assisted Individuals, 2018–2020

Enrollment

Number of HUD-assisted individuals

Total enrolled in MA, 2018–2020

1,500,385

Enrolled in MA all 3 yearsa

809,886

With the same plan all 3 years

612,233

Enrolled in MA for 2 consecutive yearsb

296,578

With the same plan both years

252,509

Enrolled in MA for 1 year or for nonconsecutive years

393,921

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: (a) Includes all HUD-assisted individuals who were identified and were enrolled in MA for at least one month during each year.

(b) Includes HUD-assisted individuals who were enrolled in MA for at least one month during two consecutive years, excluding those who were enrolled in MA during all three years.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Ownership and Types of Medicare Advantage Plan

Between 2018 and 2020, approximately 40% of all HUD-MA individuals were enrolled in plans offered by two parent organizations: UnitedHealth Group and Humana. In 2020, approximately two-thirds of HUD-MA individuals were covered by plans offered by five parent organizations: 29% by UnitedHealth Group, 13% by Humana, 8% by Anthem, 8% by Centene, and 5% by Healthfirst (Appendix B, Figure B.1). Overall MA enrollment is also highly concentrated, with UnitedHealthcare and Humana covering 44% of all MA enrollees in 2020. 31

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

11

From 2018 through 2020, the number of MA plans in which HUD-MA individuals were enrolled increased from 561 to 655, consistent with national increases in the number of MA plans available. 32 These plans were associated with more than 270 parent organizations. The largest number of plans operated in New York, California, Florida, and Texas, and most plans were concentrated in metropolitan areas.

Parent organizations can offer various types of MA plans, including traditional health maintenance organizations (HMOs) or preferred provider organizations (PPOs), which receive a capitated monthly amount per member. HUD-MA individuals overwhelmingly chose HMO plans: 72% of HUD-MA individuals chose an MA HMO, and 91% of the HUD-assisted properties with residents enrolled in MA had residents who chose an MA HMO (Appendix B, Table B.8). Among all MA enrollees, not just HUD-assisted individuals, a majority also were enrolled in HMO plans. 33

HUD Program Categories Through Which HUD-MA Individuals Received Assistance

Table 5 presents the proportion of HUD-MA individuals receiving HUD assistance through each HUD program category in 2020, as well as the percentage of HUD-assisted individuals in each HUD program category that had MA coverage. The proportion of HUD-MA individuals served by each HUD program category varied significantly. More HUD-MA individuals (42%) received voucher-based assistance than assistance through any other HUD program. Thirty-two percent of (~398,000) HUD-MA individuals received project-based Section 8

assistance, and 19% (~234,000) of HUD-MA individuals lived in public housing. Six percent (~75,000) and 0.6%

(~7,000) of HUD-MA individuals received assistance through HUD programs for older adults (Section 202) and individuals with disabilities (Section 811), respectively.

Table 5. Proportion of HUD-assisted Individuals and HUD-MA Individuals by HUD Program Category, 2020

Distribution by HUD program category

% of individuals in each

Program Category

HUD program category

All HUD-assisted individuals

HUD-MA individuals

enrolled in MAb

(N = 9.3 million)

(N = 1.2 million)

All Programs

100.0%

100.0%

13.3%

Section 202 for older adults

1.4%

6.0%

56.7%

Section 811 for individuals with

disabilities

0.4%

0.6%

22.3%

Project-Based Section 8 (PBS8)

22.0%

32.0%

19.4%

Other assisted multifamily

0.4%

0.6%

16.4%

Public housing

19.6%

18.8%

12.9%

Vouchersa

56.2%

41.9%

9.9%

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Includes all individuals receiving any HUD program category (public housing, assisted multifamily, housing choice vouchers).

(a) Vouchers include PBVs (project-based vouchers), Section 8 certificates and vouchers, and homeownership. (b) The percentage of individuals enrolled in MA in each program is calculated as the number of HUD-MA individuals divided by the number of HUD-assisted individuals receiving the specific HUD program category assistance.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

However, among HUD program categories, Section 202 for older adults and Section 811 for individuals with disabilities had the largest percentage of individuals participating in each program enrolled in MA (57% and 22%, respectively). Although these programs serve fewer people than other HUD programs (e.g., vouchers, project-based Section 8, and public housing) (Appendix B, Table B.11), HUD-MA individuals participating in these programs make up a disproportionate share of all HUD-assisted individuals enrolled in MA.

Findings regarding MA enrollment among HUD-assisted individuals in each HUD program were consistent across 2018, 2019, and 2020 (Appendix B, Table B.11, Figures B.1, B.2). Findings also were similar for HUD-assisted individuals ages 65 and older (Appendix B, Figures B.3, B.4) and for HUD-assisted individuals residing in HUD-assisted properties that had more than 10 residents with MA coverage (Appendix B, Figure B.8).

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

12

HUD-assisted Properties with MA Enrollees

Between 2018 and 2020, HUD provided federal housing assistance via 33,759 properties (Appendix B, Table B.12), providing assistance to more than 30,000 properties annually (Table 6). In 2020, among 30,114 HUD-assisted properties, 29,716 (99%) had at least one Medicare (traditional or MA) enrollee as a resident, and 26,974 (90%) had at least one MA enrollee as a resident (Appendix B, Table B.12).

In 2020, 16,249 HUD-assisted properties (54%) had more than 10 residents enrolled in MA, with almost 755,000 MA enrollees residing at these properties (Table 6). Six hundred and sixty properties had more than 10 residents enrolled in MA who were all enrolled in the same MA plan.

Table 6. Number of HUD-assisted Properties and MA Enrollees Residing in HUD-Assisted Properties Property Type

2018

2019

2020

Total HUD-assisted properties

31,720

30,313

30,114

With more than 10 MA enrolleesa

14,504

15,374

16,249

Number of MA enrollees residing at properties

647,021

702,784

754,823

With more than 10 MA enrollees and all enrollees covered by one MA

840

852

660

plan

Number of MA enrollees residing at properties

20,942

20,561

16,045

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: The terms property and project are distinct. Property_ID was created to identify a property on the basis of project or development number; hence, some properties were in multiple locations (city, county, or state). Property counts presented in this table were calculated on the basis of the property_id, irrespective of location. No restriction was placed on the number of MA plans with enrollees residing at the property.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

The number of MA plans with enrollees residing at a given HUD-assisted property varied (Figure 3; Appendix B, Table B.14). Among the HUD-assisted properties with more than 10 MA enrollees, 83% had between two and five MA plans with enrollees residing at the property: 19% of properties had 2 plans, 25% had three plans, 22%

had four plans, and 16% had five plans. Fifteen HUD-assisted properties with more than 10 MA enrollees had 10 or more MA plans represented at a property.

Figure 3. Distribution of the Number of MA Plans Present in HUD-Assisted Properties HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

13

Notes: Analysis was restricted to HUD-assisted properties with more than 10 HUD-MA residents. Properties were identified using project or development number. On the basis of this definition, some properties were identified as being in multiple locations (city, county, or state). Properties with multiple locations were counted as separate properties for this analysis.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Geographic Distribution of HUD-MA Individuals

HUD-MA individuals were unevenly distributed across the United States. ‡‡‡‡ In 2020, 41% of HUD-MA individuals resided in five states: New York, California, Florida, Texas, and Pennsylvania (Figure 4). Among all MA enrollees, not just HUD-assisted individuals, these states also had the most enrollees, with the greatest number residing in California, followed by Florida, Texas, New York, and Pennsylvania. 34 The counties in which the most HUD-MA individuals resided were Bronx County, NY (~40,900); New York County, NY (~37,600); Los Angeles County, CA (~34,000); Kings County, NY (~33,800); and Miami-Dade County, FL (~25,600) (Figure 5).

Annually, approximately one-third of HUD-MA individuals lived in a metropolitan statistical area (MSA), but data regarding whether a person resided in an MSA was unavailable for approximately 60% of HUD-MA individuals (Appendix B, Table B.15).

Figure 4. Number of HUD-MA Individuals (in Thousands) by State, 2020

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: This map depicts the number of HUD-MA indiviudals (in thousands) in each state in the contiguous United States. In 2020, 184

HUD-MA individuals resided in Wyoming, so, with rounding, the state shows 0. Alaska and Hawaii are not shown. In 2020, 36

HUD-MA individuals resided in Alaska and approximately 8,000 HUD-MA individuals resided in Hawaii.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

_______________________

‡‡‡‡ This report presents findings from 2020. Findings from 2018 and 2019 are similar and can be found using the interactive web-based dashboard that is forthcoming.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

14

Figure 5. Number of HUD-MA Individuals (in Thousands) by County, 2020

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: This map depicts the number of HUD-MA indiviudals (in thousands) in each county in the contiguous United States. Counts are presented only for counties with more than 10 HUD-MA individuals.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

In 2020, California, New York, and Pennsylvania had the most HUD-assisted properties in which at least one MA enrollee resided, as well as the most properties in which more than 10 MA enrollees resided (Table 7). For 17 states, more than 50% of their HUD-assisted properties had more than 10 MA enrollees. More than 70% of HUD-assisted properties in New York and Rhode Island had more than 10 MA enrollees.

Table 7. Count and Percentage of HUD-Assisted Properties in Which MA Enrollees Resided, by State, 2020

State

Properties with at least 1 MA

enrollee

Properties with >10 MA enrollees

Alaska

16 (16.8%)

0 (0%)

Alabama

608 (89.5%)

377 (55.5%)

Arkansas

444 (89.7%)

194 (39.2%)

Arizona

237 (92.9%)

151 (59.2%)

California

1,819 (86.0%)

1,011 (47.8%)

Colorado

383 (89.5%)

185 (43.2%)

Connecticut

509 (90.6%)

316 (56.2%)

District of Columbia

155 (92.8%)

75 (44.9%)

Delaware

116 (74.4%)

45 (28.8%)

Florida

932 (88.8%)

594 (56.6%)

775 (88.4%)

461 (52.6%)

Georgia

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

15

State

Properties with at least 1 MA

enrollee

Properties with >10 MA enrollees

Hawaii

148 (89.7%)

79 (47.9%)

Iowa

288 (89.2%)

144 (44.6%)

Idaho

130 (86.7%)

51 (34.0%)

Illinois

1,134 (85.7%)

568 (42.9%)

Indiana

580 (92.1%)

295 (46.8%)

Kansas

337 (79.9%)

122 (28.9%)

Kentucky

640 (92.0%)

296 (42.5%)

Louisiana

472 (90.8%)

238 (45.8%)

Massachusetts

1,002 (86.2%)

686 (59.0%)

Maryland

394 (65.4%)

156 (25.9%)

Maine

291 (90.7%)

136 (42.4%)

Michigan

859 (93.1%)

539 (58.4%)

Minnesota

790 (91.4%)

406 (47.0%)

Missouri

665 (93.1%)

370 (51.8%)

Mississippi

394 (88.5%)

172 (38.7%)

Montana

100 (73.0%)

34 (24.8%)

North Carolina

895 (74.6%)

433 (36.1%)

North Dakota

66 (50.4%)

8 (6.1%)

Nebraska

288 (82.5%)

88 (25.2%)

New Hampshire

205 (84.7%)

80 (33.1%)

New Jersey

774 (83.0%)

497 (53.3%)

New Mexico

165 (89.2%)

82 (44.3%)

Nevada

75 (87.2%)

38 (44.2%)

New York

1,643 (91.1%)

1,292 (71.7%)

Ohio

1,452 (92.7%)

838 (53.5%)

Oklahoma

360 (86.5%)

109 (26.2%)

Oregon

331 (85.8%)

146 (37.8%)

Pennsylvania

1,486 (92.5%)

1,043 (64.9%)

Rhode Island

314 (97.5%)

233 (72.4%)

South Carolina

460 (85.7%)

245 (45.6%)

South Dakota

156 (70.0%)

19 (8.5%)

Tennessee

711 (94.3%)

444 (58.9%)

Texas

1,408 (93.7%)

860 (57.2%)

Utah

116 (94.3%)

62 (50.4%)

Virginia

532 (86.5%)

297 (48.3%)

Vermont

120 (76.9%)

6 (3.8%)

Washington

502 (88.8%)

290 (51.3%)

Wisconsin

730 (92.6%)

372 (47.2%)

West Virginia

236 (79.7%)

108 (36.5%)

Wyoming

26 (34.7%)

1 (1.3%)

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

16

Notes: Property_ID was created to identify a property on the basis of project or development number; hence, some properties were in multiple locations (city, county, or state). For this table, property count was calculated on the basis of the property_id in each state (as identified in the HUD longitudinal data). If a property_id showed that a property was located in multiple states, that property was included in the property count of each respective state. If a property_id showed that a property had multiple locations (e.g., city or county) within a state, the property was counted only one time.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

17

DISCUSSION

Between 2018 and 2020, approximately 1.5 million HUD-assisted individuals had MA coverage. During that time, the annual number of HUD-MA individuals increased approximately 19%, from 1.0 million to 1.2 million.

The increase in HUD-MA individuals corresponded with a national increase in overall MA enrollment and a corresponding decline in enrollment in traditional Medicare. 35 Relative to the MA-enrolled population overall, approximately twice the proportion of HUD-MA individuals were younger than 65 (31% versus 15%), likely qualifying for Medicare because they had a disability. HUD-MA individuals were approximately twice as likely to identify as a person of color (64% versus 31%) and almost two and a half times as likely to have income of less than $25,000 (91% versus 38%). HUD-MA individuals also were much more likely to have full Medicaid coverage compared with the overall MA population (61% versus 12%).

Joint efforts between MA plans, their parent organizations, public housing agencies, and HUD-assisted properties to coordinate care and deliver supportive services could help improve health outcomes for HUD-MA individuals. More than one-half (54%) of HUD-MA individuals had MA coverage during all three years of the study period, and an additional almost 20% had MA coverage during two consecutive years. The majority of people who had coverage across multiple years remained enrolled in the same MA plan. Many of those MA plans have opportunities to make longer-term investments in their health.

In addition, MA plans operating in geographic areas with concentrations of HUD-MA individuals may be able to realize efficiencies in the delivery of supportive services. In 2020, about 40% of HUD-MA individuals lived in five states: New York, California, Florida, Texas, and Pennsylvania. Certain counties in those states also had high concentrations of HUD-MA individuals. In addition, place-based interventions could be provided at the more than 16,000 HUD-assisted properties with more than 10 residents enrolled in MA (collectively housing more than 750,000 MA enrollees). Housing-with-services models, such as SASH§§§§

*****

and IWISH,

offer

examples of how to provide care coordination and coordinate supportive services. However, individual stakeholders will need to assess the necessary number of individuals with MA coverage or the number of MA plans with enrollees at a property when deciding if and how to provide care coordination or supportive services.

MA plans and parent organizations could partner with local public health departments, administrators, public housing agencies, and managers of HUD-assisted properties to—

• Identify concentrations of MA enrollees receiving federal housing assistance residing in HUD-assisted properties and certain geographic areas (e.g., state, MSA, county);

• Analyze health plan data to better understand the health status and health care needs of HUD-MA individuals residing in a property or geographic area;

• Assess HUD-MA individuals for social needs (screening may be conducted for all MA plan members or targeted to certain individuals based on specific criteria); and

• Provide place-based interventions (e.g., care coordination and supportive services) to support MA enrollees receiving project-based federal housing assistance.

MA plans may want to consider how supplemental benefits could be used to help address the health or overall function of members receiving federal housing assistance.

An interactive web-based dashboard that accompanies this report is forthcoming. The dashboard allows interested stakeholders to explore the distribution of HUD-MA individuals nationally, as well as by state, _______________________

§§§§ Support and Services at Home program.

***** Integrated Wellness in Supported Housing model.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

18

county, and HUD-assisted property. Users also can assess the number of HUD-MA individuals by MA plan and parent organization.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

19

CONCLUSION

Geographic concentrations of MA enrollees who receive federal housing assistance present opportunities to facilitate the delivery of care coordination and supportive services for a population at higher risk for adverse health outcomes. MA plans, parent organizations, public housing agencies, and HUD-assisted properties could consider taking a number of actions to support this population.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

20

APPENDIX A: DETAILED METHODOLOGY

Study Population

The study population included all individuals receiving federal housing assistance that also had health care coverage through a Medicare Advantage plan for at least one month in a particular calendar year (CY) (Figure A.1). Table A.1 details the study population specifications.

Figure A.1: Study Population (HUD-MA Individuals) (Shown with 2020 Data)a

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Note:

(a) The same calendar year was used for receipt of federal housing assistance and MA coverage for the study population.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data. Medicare enrollment based on Medicare enrollment charts available at https://www2.ccwdata.org/web/guest/medicare-charts/medicare-enrollment-charts.

Table A.1: Study Population Specifications

Specification

HUD-assisted individuals

Medicare Advantage-

enrolled individuals

Individuals receiving federal housing assistance, identified on the basis

of the type of HUD program assistance the recipient or head of

household received:

• Project-based Section 8

All individuals in the Medicare

Federal housing

• Section 236 (Interest Reduction and Rental Assistance Payments

enrollment database who

assistance/Medicare

[RAPs])

were enrolled in an MA plan

Advantage coverage • Rent Supplement, RAP

for at least one month during

• Section 211 Below-Market Interest Rate (BMIR) mortgage insurance the calendar year

• Section 202 Project Rental Assistance Contract (PRAC)

• Section 202/162 Project Assistance Contract (PAC)

• Section 811 PRAC

Time frame

CY 2018–CY 2020

CY 2018–CY 2020

Unique MA enrollee

(irrespective of number of

Data level or unit of Unique individual receiving federal housing assistance (irrespective of months of coverage or

analysis

whether head of household or other dependent and number of months

of coverage during the calendar year)

number of plans the individual

was enrolled in during the

calendar year)

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Source: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

21

Data

Table A.2: Data Sources and Data Elements

Agency

Data source/table

Data elements

Social Security number, age, gender, race, ethnicity,

Longitudinal data file

income, disability indicator, household size, participation

HUD

(Primary source for records associated with individuals

in special program (e.g., HOPE), development or project

receiving federal housing assistance)

number, structure type, HUD program indicator, ZIP Code,

census tract, city, socioeconomic factor of location of the

property

HUD

Tenant Rental Assistance Certification System (TRACS)

Metropolitan statistical area (MSA), property ID, property

category name, property/owner/management name

HUD

Inventory Management System (IMS)/Public and Indian

Metropolitan statistical area (MSA), property ID,

Housing (PIH) Information System (PIC)

owner/management

CMS

BENE ID to SSN Crosswalk

SSN, beneficiary ID

Medicare Master Beneficiary Summary File—Base (MBSF) Beneficiary ID, MA plan number by month, plan type, age, CMS

(Primary source for records associated with individuals

date of birth (DOB), ZIP Code, Part C contract number,

with Medicare coverage)

HMO coverage months, Medicare-Medicaid dual eligibility

CMS

Medicare Plan Characteristics File

Beneficiary ID, benefits package, premium, cost-sharing

HMO = health maintenance organization. HOPE = Homeownership and Opportunity for People Everywhere. HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage. SSN = Social Security number.

Source: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Data Linkage Methodology

We linked HUD and CMS data using a multi-step process:

1. Three years of HUD longitudinal data were used to identify Social Security numbers (HUD SSNs) of individuals receiving federal housing assistance (irrespective of whether they were head of household or member);

2. The list of HUD SSNs was used to identify BENE_ID in the CMS “BENE ID to SSN Crosswalk” data (Beneficiary Match List); and

3. All enrollment records associated with the Beneficiary Match List were extracted for 2018–2020 (HUD-Medicare). Enrollment records contain 12 indicators for monthly MA plan coverage

(ptc_plan_type_cd) that were used to identify individuals who had MA plan coverage (HUD-MA).

Refer to the “Analytic Data Preparation” Section for additional information related to preparing the final analytic data used for calculating metrics included in this report.

Figure A.2: Data Matching to Identify the Study Population

HUD-assisted individuals

HUD-Medicare individuals

HUD-MA enrollees

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Source: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

22

Table A.3: Medicare and HUD Data Linkage Summary, 2018–2020

Finder file and MBSF SSN match

Number of SSNs in

SSNs with more than

Number of MBSF

(indicator and label)

finder file

one beneficiary IDa

beneficiary IDs

0: No match

8,656,583

-

8,656,583

1: Match

2,949,041

6,379

2,955,437

9: Invalid SSN

43,781

-

43,781

TOTAL

11,649,405

11,655,801

HUD = U.S. Department of Housing and Urban Development. MBSF = Master Beneficiary Summary File. SSN = Social Security number.

Notes: (a) Medicare beneficiary identification (ID) can change for multiple reasons; 6,363 SSNs had two beneficiary IDs, 15 SSNs had three beneficiary IDs, and one SSN had four beneficiary IDs.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Analytic Data Preparation Methodology

The final analytic data contained all individuals who received federal housing assistance (present in the HUD

longitudinal data with valid SSN and HUD program identifiers) in each of the three years. The data contained—

1. Demographic characteristics captured in HUD data (e.g., gender, age, race, ethnicity, head of household, household size, and income);

2. HUD program category (e.g., Section 202);

3. HUD property identifier;

4. Geographic information captured in HUD data (e.g., city, county, state, MSA, property latitude and longitude);

5. Indicators for having Medicare coverage and MA coverage based on head of household or the member; and

6. Number of MA plans, most recent MA plan, and MA plan parent organization associated with the member in that year.

We constructed the analytic data using the following data as inputs:

1. Input 1 (D_HUD): HUD longitudinal data containing records for all individuals receiving federal housing assistance. The data contain a separate row for each individual, irrespective of whether the individual was head of the household or not. For example, for a family of four with two children and two adults, the data have four separate line items, one for each individual. Each record also includes the SSN for head of household. These data were developed by merging multiple components of HUD longitudinal data: (a) member-level data containing member information; (b) head of household data containing distinct records only related to head of household; and (c) HUD ID and SSN crosswalk.

2. Input 2 (D_Finder): Beneficiary Match List finder file containing a unique list of SSN and BENE_ID (refer to “Data Linkage Methodology” above for more information).

3. Input 3 (D_HUDMed): Medicare enrollment records for individuals in the Beneficiary Match List.

4. Input 4 (D_Plan): Medicare plan characteristics data.

Processing steps to construct the analytic data included:

Step 1. Flagged records indicating whether a match to Medicare enrollment was based on member SSN or head of household SSN:

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

23

a. Matched D_HUD to D_Finder using member SSN. If member SSN matched and member SSN was the same as head of household SSN in D_HUD, then flagged the observation as match group 2. If member SSN matched and member SSN was different from head of household SSN in D_HUD, then flagged the observation in D_HUD as match group 3.

b. Matched D_HUD to D_Finder using head of household SSN. If there was a match and member SSN

was the same as head of household SSN, then classified as match group 2. If not, classified as match group 1.

c. Match groups created:

i.

Group 1—Head of household SSN only matches to the Medicare Master Beneficiary

Summary File Base (MBSF)

ii.

Group 2—Member and head of household SSN match to MBSF; member SSN is the same as

head of household SSN (head of household SSNs in group 1 are part of group 2, except for 43 cases across 3 years)

iii.

Group 3—Member and head of household SSN match to MBSF; member SSN is not the

same as head of household SSN

iv.

No match—All records not flagged within groups 1, 2, or 3

For all counts related to MA coverage, only records associated with groups 2 and 3 were used to avoid count duplication.

Step 2. Merged D_HUD to HUD-Med based on year and SSN

Step 3. Obtained plan characteristics from D_plan for all 12 months for matched groups 1, 2, and 3 (using member and head of household SSN/MBSF bene_ID).

a. For group 3 (member and head of household SSN are different, but both matched with Medicare enrollment), we used the plan ID information for member SSN.

b. We created coverage indicators for members and heads of household based on member and head of household MA plan IDs. If either a member or head of household had an MA plan ID, then we identified the record associated with the individual who had MA coverage. Both a member and a head of household can have MA plan IDs. Because HUD administrative data are structured to have separate records for every individual, the data contain separate line records associated with head of household and relevant plan information.

Step 4. Created variables for analysis. Refer to the “Variable Mapping” section for specific details. Variables included the following:

a. An indicator for Medicare and MA plan coverage (0/1 based on the match);

b. MA plan enrollment variables (number of MA plans in which an individual was enrolled within a year, dually eligible at any time during the months of MA enrollment);

c. Standardized groups for race, age, and HUD program benefit; and

d. A property identifier (concatenated HUD project or development number information).

Variable Mapping

As part of the analytic data development, we performed data transformations for select variables of interest.

This section discusses the data transformations performed.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

24

MA Plan

Member MA plan coverage during a year was captured by creating four fields: (1) whether the member was enrolled in an MA plan during any month in the FY; (2) the number of months the member had coverage through a MA plan (i.e., for the full 12 months or fewer than 12 months [partial]); (3) MA plan with which the member was enrolled during the last month the member had MA coverage in a year; and (4) the number of MA plans with which a member was enrolled during a single year. These fields were generated using Part C

coverage information captured monthly in the CMS MBSF and Plan Characteristics File data:†††††

• HUD-MA indicator: 1 (i.e., had MA coverage) if PTC_PLAN_TYPE_CD and PTC_CNTRCT_ID are not null/missing for at least one month in the year, otherwise 0 (i.e., had no MA coverage);

• Number of months with MA plan coverage: number of months with non-null or non-missing PTC_PLAN_TYPE_CD and PTC_CNTRCT_ID;

• MA plan in the last month with MA coverage in a year: PLAN_NAME, PARENT_ORGANIZATION; and

• Number of MA plans member was enrolled in during a single year: number of different PLAN_NAME

within a year.

Race

The member race variable in HUD’s longitudinal data was used to create the race field. Because individuals can select multiple races, we created a hierarchical race category in which individuals with multiple race categories were grouped as “Multiple” race. Below is the SAS code used to create the race field that was used to develop the findings.

/* To avoid potential missing or other issues, create numeric indicator for race */

if upcase(MBR_RACE_WHITE_INDR)='Y' then white=1; else white=0;

if upcase(MBR_RACE_BLACK_INDR)='Y' then black=1; else black=0;

if upcase(MBR_RACE_ASIAN_INDR)='Y' then asian=1; else asian=0;

if upcase(MBR_RACE_AMRCN_INDIAN_INDR)='Y' then NA=1; else NA=0;

if upcase(MBR_RACE_HWN_PACIFIC_INDR)='Y' then PI=1; else PI=0;

/* Assign hierarchical race categories */

if white + black + Asian + NA + PI > 1 then race = ”Multiple”;

else if white=1 then race = ”White”;

else if black=1 then race = ”Black”;

else if Asian=1 then race = ”Asian”;

else if native=1 then race = ”Native American”;

else if pacific=1 then race = ”Pacific Islander”;

else race = ”Other”;

_______________________

††††† Refer to CMS MBSF Base data documentation, available at https://resdac.org/cms-data/files/mbsf-base/data-documentation, for a description of the data elements and values.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

25

Federal Housing Assistance Program Categories

Table A.4 provides the categorization of HUD programs into program categories and the relevant forms.

Table A.4: Federal Housing Assistance Program Categories

HUD program

Program categories

Form

CE: Section 8 Certificates

Vouchers

50058

H

Vouchers

50058

H1: Project-based Section 8

Project-Based Section 8 (PBS8)

50059

H2: Rent Supplement

Other assisted multifamily

50059

H3: RAP

Other assisted multifamily

50059

H4: Section 236

Other assisted multifamily

50059

H5: BMIR

Other assisted multifamily

50059

H6

Section 811 for individuals with

disabilities

50059

H7: Section 202 PRAC

Section 202 for older adults

50059

H8: Section 811 PRAC

Section 811 for individuals with

disabilities

50059

H9: Section 202/162 PAC

Section 202 for older adults

50059

MR: Mod Rehab

Other assisted multifamily

50058

P: Public Housing

Public housing

50058

PR: Moving to Work (MTW) Project-Based

Voucher

Vouchers

50058 MTW

T: MTW Tenant-Based Voucher

Vouchers

50058 MTW

VO: Section 8 Vouchers

Vouchers

50058

BMIR = Below-Market Interest Rate. PAC = Project Assistance Contract. PRAC = Project Rental Assistance Contract. RAP = Rental Assistance Payment.

Notes: Vouchers include tenant-based housing choice voucher (HCV) programs (CE, H, T, and VO) and project-based Moving to Work (MTW) voucher programs. HUD-5 forms are available at

https://www.hud.gov/program_offices/administration/hudclips/forms/hud5.

Source: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Property Identifier

We created a unique identifier for properties concatenating HUD project or development number fields captured in the HUD data (Table A.5).

Table A.5: HUD-assisted Property Identifier

Variable

Definition

dvlpt_num

Code that uniquely identifies a project or a development to which a public housing unit belongs proj_name

Name of project, if applicable (TRACS Only)

proj_num

FHA number (TRACS Only)

FHA = Federal Housing Administration. TRACS = Tenant Rental Assistance Certification System.

Source: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Dual Eligible Indicators

Individuals were identified as having full Medicaid coverage based on DUAL_ELGBL_CD in the CMS MBSF data and flagged if—

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

26

1. DUAL_ELGBL_CD had values 02, 04, 08 (refer to Table A.6) and had a valid MA plan ID (non-missing) for the month.

2. Individual had full Medicaid coverage in any month with MA coverage during the year.

Individuals were identified as Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified Disabled Working Individual (QDWI), or Qualifying Individual (QI) based on DUAL_ELGBL_CD 01 / 02 /03 / 04 / 05 / 06 in the CMS MBSF data during any of the months with valid MA coverage.

Individuals were identified as not having Medicaid if the DUAL_ELGBL_CD was not between 01 and 08 in any of the months with MA coverage.

Table A.6: Mapping for Medicaid Coverage

Full/partial

Code value

Medicaid

QMB/SLMB/

coverage

QDWI/QI

0: Eligible is not a Medicare beneficiary

1: Eligible is entitled to Medicare-Qualified Medicare Beneficiary (QMB) only

Partial

Yes

2: Eligible is entitled to Medicare-QMB and Medicaid coverage, including prescription drugs Full

Yes

3: Eligible is entitled to Medicare-Specified Low-Income Medicare Beneficiary (SLMB) only Partial

Yes

4: Eligible is entitled to Medicare-SLMB and Medicaid coverage, including prescription drugs Full

Yes

5: Eligible is entitled to Medicare- Qualified Disabled Working Individual (QDWI)

Partial

Yes

6: Eligible is entitled to Medicare-Qualifying Individuals (QI)

Partial

Yes

8: Eligible is entitled to Medicare-Other Dual Eligibles (Non-QMB, SLMB, QDWI, or QI), including prescription drugs

Full

9: Eligible is entitled to Medicare—but without Medicaid coverage (This code is to be used only with specific CMS approval)

10: Separate CHIP Eligible is entitled to Medicare

Null/missing: Source value is missing or unknown

CHIP = Children's Health Insurance Program. CMS = Centers for Medicare & Medicaid Services. QDWI = Qualified Disabled Working Individual. QI = Qualifying Individual. QMB = Qualified Medicare Beneficiary. SLMB = Specified Low-Income Medicare Beneficiary.

Source: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

27

Limitations

Table A.7: Data and Analytical Limitations

Limitation

Description

Mitigation

A small number of individuals in the HUD

When producing counts, we ensured that distinct SSNs

Multiple

administrative data had multiple records in the same

were counted for relevant metrics to avoid double

records for an

year. Individuals had multiple records for various

counting. Depending on the analysis (e.g., count by

individual

reasons, including being associated with children,

HUD program), we included individuals for relevant

having different residence addresses, and receiving

programs and present findings with notes to assist with

assistance through different HUD program categories.

interpretability.

For metrics related to MA penetration (e.g., total

number and percentage of individuals having MA), we

counted an individual only once in a year, irrespective

of the number of different plans in which an individual

was enrolled.

Multiple plans Some individuals with Medicare Advantage coverage

For metrics associated with stability of plan coverage

were enrolled in multiple plans during a calendar year. (e.g., single/multiple plans), we used monthly plan information to create a summary variable that counts

the number of distinct plans a member had in a year.

For metrics displaying count of members by plan (e.g.,

list of property and plan with count of individuals), we

used the more recent plan information.

Restrictions on reporting counts of individuals (i.e., not

reporting counts of fewer than 10 for HUD and CCW

These restrictions should be taken into account when

interpreting findings (e.g., counts from property-level

Cell size

and fewer than 11 for exporting data outside the CMS

data warehouse environment) limit the information

findings in a state may not add to the state-level

available for certain geographic areas, properties, or

counts). We included notes to assist with

Medicare Advantage plans.

interpretation, as applicable.

CCW = Chronic Conditions Data Warehouse. CMS = Centers for Medicare & Medicaid Services. HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Source: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

28

APPENDIX B: DETAILED FINDINGS

This appendix provides detailed results not included in the main section of the report.

How many individuals received federal housing assistance (HUD-assisted)? Among HUD-

assisted individuals, how many had Medicare coverage (HUD-Medicare) and Medicare

Advantage coverage (HUD-MA)?

Table B.1: Total HUD-assisted, HUD-Medicare, and HUD-MA Individuals, by Year and Linkage Logic Individuals receiving federal housing assistance (HUD-assisted

individuals)

2018

2019

2020

2018–2020

Total

9,512,659

9,417,880 9,318,101

11,648,004

All ages - Match by SSN

HH member match (HUD-Medicare)

2,558,746

2,518,407 2,454,457

2,949,041

% with Medicare coverage among HUD

26.9%

26.7%

26.3%

25.3%

With Medicare Advantage (HUD-MA)—SSN match only

1,043,483

1,143,783 1,242,970

1,500,385

% with MA coverage among HH SSN matches

40.8%

45.4%

50.6%

50.9%

% with MA coverage among HUD-assisted individuals

11.0%

12.1%

13.3%

12.9%

Among individuals with MA coverage across all ages: Other

matches

HH Member SSN + DOB match

1,009,919

1,108,416 1,205,698

1,453,982

% matches among MA SSN only

96.8%

96.9%

97.0%

96.9%

HH Member SSN + DOB + Gender match

996,620

1,093,219 1,188,487

1,433,116

% matches among MA SSN only

95.5%

95.6%

95.6%

95.5%

Ages 62+

HUD-assisted individuals ages 62+

1,824,703

1,873,779 1,910,782

% of all HUD-assisted indiviudals

19.2%

19.9%

20.5%

HUD-Medicare match

1,755,928

1,781,659 1,761,628

% with Medicare coverage

96.2%

95.1%

92.2%

HUD-MA–SSN match

785,830

862,543

939,437

% with MA coverage among HUD-Medicare individuals

44.8%

48.4%

53.3%

% with MA coverage among HUD-assisted individuals

43.1%

46.0%

49.2%

Ages 65+

HUD-assisted individuals ages 65+

1,525,369

1,563,541 1,596,114

% of all HUD-assisted individuals

16.0%

16.6%

17.1%

HUD-Medicare match

1,481,866

1,515,037 1,535,101

% with Medicare coverage

97.1%

96.9%

96.2%

HUD-MA—SSN match

719,598

786,324

853,610

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

29

Individuals receiving federal housing assistance (HUD-assisted

individuals)

2018

2019

2020

2018–2020

% with MA coverage among HUD-Medicare individuals

48.6%

51.9%

55.6%

% with MA coverage among HUD-assisted individuals

47.2%

50.3%

53.5%

DOB = date of birth. HH = head of household. HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

MBSF = Master Beneficiary Summary File. SSN = Social Security number.

Notes: MA plan was identified using Part C plan type indicator (ptc_plan_type_cd) in the MBSF data. Individuals can have multiple plans in a year or may have MA coverage for part of the year. Individuals are counted only once in the MA plan counts in a year, as long as the individual had a valid MA plan indicator for at least one month in the year.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

30

What proportion of HUD-assisted individuals had Medicare and MA coverage?

Table B.2: Proportion of HUD-assisted Individuals with Medicare Coverage (traditional and MA) and MA Coverage, by Year and Select Demographic Characteristics

Demographic

characteristics

Proportion of HUD-assisted individuals

Proportion of HUD-assisted individuals with MA coverage (HUD-MA)

with Medicare coverage (HUD-Medicare) (%)

(%)

2018

2019

2020

2018–2020

2018

2019

2020

2018–2020

Total

All individuals

26.9

26.7

26.3

25.3

11.0

12.1

13.3

12.9

Elderly (62+)

96.2

95.1

92.2

92.6

43.1

46.0

49.2

49.7

Non-elderly (0–61)

10.4

9.8

9.4

9.9

3.4

3.7

4.1

4.2

Age

Elderly (65+)

97.1

96.9

96.2

96.2

47.2

50.3

53.5

53.9

Non-elderly (0–64)

13.5

12.8

11.9

12.9

4.1

4.6

5.0

5.2

Female

28.7

28.4

28.0

26.9

12.1

13.4

14.7

14.2

Gender

Male

23.9

23.8

23.5

22.6

9.1

10.1

11.1

10.7

White

36.2

36.2

35.8

33.9

14.0

15.5

17.1

16.3

Black

17.7

17.6

17.3

16.8

7.8

8.8

9.7

9.4

Asian

52.1

52.7

52.6

50.4

19.7

21.9

23.9

23.6

Race

American Indian

21.8

21.4

21.0

19.6

7.0

7.8

8.7

8.1

Pacific Islander

13.8

13.3

13.0

13.4

6.1

6.4

6.9

7.1

Multiple races

15.6

15.9

16.1

14.8

7.2

8.3

9.3

8.3

Otherb

27.3

27.3

27.3

25.1

13.2

14.5

15.8

14.4

Hispanic

22.0

22.6

22.4

21.1

11.5

13.1

14.0

13.3

Ethnicity

Non-Hispanic

28.0

27.8

27.4

26.4

10.8

11.9

13.2

12.9

No disability

15.4

15.2

14.8

14.9

6.5

7.1

7.7

7.6

Disabilitya

Disability

67.0

65.3

64.2

63.7

26.5

29.0

31.8

31.8

Household size 1

74.8

73.2

71.6

70.9

31.7

34.2

37.1

36.8

Household size 2

29.9

29.3

28.4

27.0

11.7

12.9

14.0

13.1

Household size

Household size 3–5

5.1

4.8

4.6

4.8

1.7

1.8

2.0

2.1

Household size 6+

2.0

1.8

1.7

1.9

0.6

0.6

0.7

0.7

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: For proportion, denominator is the count of distinct individuals who received federal housing assistance and had a specific demographic characteristic based on information captured in HUD longitudinal data during the specific period; numerator is, among denominator population, the number having Medicare (including MA) or MA coverage in the period. Demographics for individuals can change over time. For this table, used the first-year information for an individual. (a) Disability is based on mbr_dsblty_indr field captured April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

31

in the HUD longitudinal data. Definitions to establish eligibility or obtain HUD program benefits as a person with disabilities vary by program. See “Appendix B: Applicable Definition of Disability for Determining HUD Eligibility” in A Primer on HUD Programs and Associated Administrative Data, available at https://www.cdc.gov/nchs/data/datalinkage/primer-on-

hud-programs.pdf. (b) “Other” race includes missing or unknown race.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

April 2024

Medicare Advantage Coverage Among Individuals Receiving

Federal Housing Assistance

32

What was the demographic composition of HUD-assisted individuals, including those with Medicare (Traditional and MA and

MA-only) coverage?

Table B.3: Number of HUD-assisted, HUD-Medicare, and HUD-MA Individuals (in Thousands), by Select Demographic Characteristics (2018-2020) Demographic Characteristic

HUD-Assisted

HUD-Medicare

HUD-MA

2018

2019

2020

2018–

2020

2018

2019

2020

2018–

2020

2018

2019

2020

2018–

2020

Total

All individuals

9,513

9,418

9,318

11,648

2,559

2,518

2,454

2,949

1,043

1,144

1,243

1,500

Elderly (62+)

1,825

1,874

1,911

2,281

1,756

1,782

1,762

2,112

786

863

939

1,133

Age

Non-elderly (0–61)

7,688

7,544

7,407

9,555

803

737

693

950

258

281

304

404

Elderly (65+)

1,525

1,564

1,596

1,916

1,482

1,515

1,535

1,844

720

786

854

1,032

Non-elderly (0–64)

7,987

7,854

7,722

9,921

1,077

1,003

919

1,277

324

357

389

519

Gender

Female

5,943

5,878

5,810

7,199

1,704

1,672

1,627

1,938

719

786

852

1,022

Male

3,550

3,519

3,487

4,450

847

838

819

1,007

321

354

386

476

White

4,073

3,961

3,857

5,055

1,474

1,432

1,381

1,715

571

613

658

823

Black

4,565

4,560

4,547

5,615

808

804

789

942

358

401

441

530

Asian

281

279

279

327

146

147

146

165

55

61

66

77

Race

American Indian

81

82

83

114

18

18

17

22

6

6

7

9

Pacific Islander

70

70

70

92

10

9

9

12

4

4

5

7

Multiple races

157

168

180

235

24

27

29

35

11

14

17

20

Otherb

288

299

304

417

78

82

83

105

38

44

48

60

Ethnicity

Hispanic

1,800

1,922

1,896

2,336

396

434

425

493

207

251

266

310

Non-Hispanic

7,709

7,491

7,416

9,478

2,162

2,085

2,029

2,502

836

892

977

1,218

Disabilitya

No disability

7,397

7,240

7,150

9,273

1,140

1,097

1,062

1,379

483

513

553

705

Disability

2,116

2,178

2,168

2,657

1,419

1,422

1,393

1,691

561

631

690

844

Household size 1

2,371

2,413

2,431

2,997

1,773

1,765

1,741

2,125

751

826

903

1,104

Household

Household size 2

1,800

1,787

1,772

2,491

539

524

503

673

212

231

248

327

size

Household size 3–5

4,362

4,255

4,175

5,691

221

205

190

273

73

78

84

118

Household size 6+

950

936

922

1,288

19

17

16

25

6

6

6

9

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Demographic characteristics are based on information captured in HUD longitudinal data during the specific period. Demographics for individuals can change over time. For this table, we used the first-year information for an individual. (a) Disability is based on mbr_dsblty_indr field captured in HUD longitudinal data. Definitions to establish eligibility or obtain HUD program benefits as a person with disabilities vary by program. See “Appendix B: Applicable Definition of Disability for Determining HUD Eligibility” in A Primer on HUD

Programs and Associated Administrative Data, available at https://www.cdc.gov/nchs/data/datalinkage/primer-on-hud-programs.pdf. (b) “Other” race includes missing or unknown race.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

33

Table B.4: Distribution of HUD-Assisted, HUD-Medicare, and HUD-MA Populations, by Select Demographic Characteristics (2018–2020) Demographic Characteristic

HUD-Assisted Individuals

HUD-Medicare Individuals

HUD-MA Individuals

2018

2019

2020

2018–

2020

2018

2019

2020

2018–

2020

2018

2019

2020

2018–

2020

Total

All individuals (in '000s)

9,513

9,418

9,318

11,648

2,559

2,518

2,454

2,949

1,043

1,144

1,243

1,500

Elderly (62+)

19.2%

19.9%

20.5%

19.6%

68.6%

70.7%

71.8%

71.6%

75.3%

75.4%

75.6%

75.5%

Non-elderly (0–61)

80.8%

80.1%

79.5%

82.0%

31.4%

29.3%

28.2%

32.2%

24.7%

24.6%

24.4%

26.9%

Age

Elderly (65+)

16.0%

16.6%

17.1%

16.4%

57.9%

60.2%

62.5%

62.5%

69.0%

68.7%

68.7%

68.8%

Non-elderly (0–64)

84.0%

83.4%

82.9%

85.2%

42.1%

39.8%

37.5%

43.3%

31.0%

31.3%

31.3%

34.6%

Female

62.5%

62.4%

62.4%

61.8%

66.6%

66.4%

66.3%

65.7%

68.9%

68.7%

68.5%

68.1%

Gender

Male

37.3%

37.4%

37.4%

38.2%

33.1%

33.3%

33.4%

34.1%

30.8%

31.0%

31.1%

31.7%

White

42.8%

42.1%

41.4%

43.4%

57.6%

56.9%

56.3%

58.2%

54.7%

53.6%

53.0%

54.8%

Black

48.0%

48.4%

48.8%

48.2%

31.6%

31.9%

32.1%

31.9%

34.3%

35.0%

35.5%

35.3%

Asian

3.0%

3.0%

3.0%

2.8%

5.7%

5.8%

6.0%

5.6%

5.3%

5.3%

5.3%

5.1%

Race

American Indian

0.9%

0.9%

0.9%

1.0%

0.7%

0.7%

0.7%

0.8%

0.5%

0.6%

0.6%

0.6%

Pacific Islander

0.7%

0.7%

0.8%

0.8%

0.4%

0.4%

0.4%

0.4%

0.4%

0.4%

0.4%

0.4%

Multiple races

1.6%

1.8%

1.9%

2.0%

1.0%

1.1%

1.2%

1.2%

1.1%

1.2%

1.3%

1.3%

Otherb

3.0%

3.2%

3.3%

3.6%

3.1%

3.2%

3.4%

3.6%

3.6%

3.8%

3.9%

4.0%

Hispanic

18.9%

20.4%

20.4%

20.1%

15.5%

17.2%

17.3%

16.7%

19.9%

22.0%

21.4%

20.7%

Ethnicity

Non-Hispanic

81.0%

79.5%

79.6%

81.4%

84.5%

82.8%

82.7%

84.9%

80.1%

78.0%

78.6%

81.2%

No disability

77.8%

76.9%

76.7%

79.6%

44.6%

43.6%

43.3%

46.8%

46.3%

44.9%

44.5%

47.0%

Disabilitya

Disability

22.2%

23.1%

23.3%

22.8%

55.4%

56.4%

56.8%

57.3%

53.8%

55.1%

55.5%

56.2%

Household size 1

24.9%

25.6%

26.1%

25.7%

69.3%

70.1%

70.9%

72.1%

71.9%

72.2%

72.6%

73.6%

Household

Household size 2

18.9%

19.0%

19.0%

21.4%

21.1%

20.8%

20.5%

22.8%

20.3%

20.2%

19.9%

21.8%

size

Household size 3–5

45.9%

45.2%

44.8%

48.9%

8.6%

8.1%

7.7%

9.3%

7.0%

6.9%

6.8%

7.8%

Household size 6+

10.0%

9.9%

9.9%

11.1%

0.7%

0.7%

0.6%

0.8%

0.5%

0.5%

0.5%

0.6%

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Demographic characteristics are based on information captured in HUD longitudinal data during the specific period. Demographics for individuals can change over time. For this table, used the first-year information for an individual. (a) Disability is based on mbr_dsblty_indr field captured in the HUD longitudinal data. Definitions to establish eligibility or obtain HUD program benefits as a person with disabilities vary by program. See “Appendix B: Applicable Definition of Disability for Determining HUD Eligibility” in A Primer on HUD

Programs and Associated Administrative Data, available at https://www.cdc.gov/nchs/data/datalinkage/primer-on-hud-programs.pdf. (b) “Other” race includes missing or unknown race.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

34

Table B.5: Distribution of HUD-Medicare and HUD-MA Populations Ages 65+, by Select Demographic Characteristics (2018–2020) Demographic Characteristic

With Medicare coverage

With MA coverage

2018

2019

2020

2018–2020

2018

2019

2020

2018–2020

Total

All in

dividuals (in 1,000s)

1,482

1,515

1,535 1,844

720

786

854

1,032

Female

69.1%

68.8%

68.5%

68.1%

70.3%

70.0%

69.7%

69.3%

Gender

Male

30.5%

30.8%

31.1%

31.7%

29.3%

29.6%

29.8%

30.4%

White

60.2%

59.0%

57.9%

60.0%

57.0%

55.5%

54.5%

56.6%

Black

25.6%

26.5%

27.2%

27.1%

29.5%

30.5%

31.2%

31.0%

Asian

8.6%

8.6%

8.7%

8.1%

7.2%

7.3%

7.3%

7.0%

Race

American Indian

0.6%

0.6%

0.6%

0.7%

0.5%

0.5%

0.6%

0.6%

Pacific Islander

0.4%

0.4%

0.4%

0.4%

0.4%

0.4%

0.4%

0.4%

Multiple Race

0.9%

1.0%

1.2%

1.2%

1.1%

1.2%

1.4%

1.3%

Otherb

3.7%

3.9%

4.1%

4.2%

4.3%

4.5%

4.6%

4.7%

Hispanic

17.0%

19.1%

19.3%

18.5%

21.9%

24.5%

24.0%

23.1%

Ethnicity

Non-Hispanic

82.9%

80.9%

80.7%

83.1%

78.1%

75.5%

76.0%

79.0%

No Disability

60.9%

59.6%

59.0%

61.4%

61.9%

60.2%

59.6%

62.0%

Disabilitya

Disability

39.1%

40.4%

41.0%

41.6%

38.1%

39.8%

40.4%

41.2%

Household Size 1

75.1%

75.3%

75.7%

76.9%

75.8%

75.9%

76.4%

77.4%

Household

Household Size 2

20.5%

20.3%

20.1%

21.5%

19.8%

19.6%

19.3%

20.7%

size

Household Size 3–5

3.9%

3.8%

3.8%

4.4%

4.0%

3.9%

3.9%

4.4%

Household Size 6+

0.3%

0.3%

0.3%

0.3%

0.3%

0.3%

0.2%

0.3%

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Demographic characteristics are based on information captured in HUD longitudinal data during the specific period. Demographics for individuals can change over time. For this table, used the first-year information for an individual. (a) Disability is based on mbr_dsblty_indr field captured in the HUD longitudinal data. Definitions to establish eligibility or obtain HUD program benefits as a person with disabilities vary by program. See “Appendix B: Applicable Definition of Disability for Determining HUD Eligibility” in A Primer on HUD

Programs and Associated Administrative Data, available at https://www.cdc.gov/nchs/data/datalinkage/primer-on-hud-programs.pdf. (b) “Other” race includes missing or unknown race.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

35

Did MA Plan coverage vary by size of household or income?

Table B.6: Number of HUD-MA Individuals and Duration of MA Coverage During a Year, by Household Size and Income (2018–2020)

Characteristics

2018

2019

2020

Number of

Number of

Number of

Number of months with Number of months with Number of months with

individuals MA coverage individuals MA coverage individuals MA coverage

(avg, std)

(avg, std)

(avg, std)

1

750,588

11.1 (2.5)

825,927

11.2 (2.3)

902,954

11.4 (2.1)

Household

2

211,506

10.9 (2.7)

230,763

11.1 (2.4)

247,542

11.3 (2.2)

size

3–5

73,473

10.7 (2.9)

78,418

10.8 (2.7)

84,106

11.1 (2.5)

6+

5,518

10.5 (3.0)

5,789

10.7 (2.8)

6,088

10.9 (2.6)

<$10,000

303,390

10.8 (2.8)

315,425

11.0 (2.5)

322,397

11.2 (2.3)

$10,000–

HUD

$24,999

655,156

11.1 (2.5)

727,938

11.2 (2.3)

811,089

11.4 (2.1)

estimated

$25,000–

household

$49,999

77,278

11.1 (2.4)

90,963

11.2 (2.3)

99,400

11.3 (2.1)

income

$50,000–

$99,999

7,236

11.1 (2.5)

8,952

11.1 (2.4)

9,576

11.2 (2.3)

$100,000+

544

11.1 (2.5)

622

11.1 (2.4)

646

11.3 (2.1)

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Characteristics based on information captured in HUD longitudinal data during the specific period. Household income calculated using HUD methodology.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Did HUD-MA individuals have MA plan coverage for all 12 months? Did individuals switch

plans?

Table B.7: Number of HUD-MA Individuals and Percentage of Decedents, by Duration of MA Coverage and Number of MA Plans in Which Enrolled During a Year

Duration of coverage/multiple plan indicator

Number of HUD-MA individuals

% decedents (among

HUD-MA)

2018

2019

2020

2018

2019

2020

Multiple plans

79,920

94,210

110,500

0.23%

0.24%

0.40%

MA plan coverage = Single plan

784,244

869,744

976,488

0.28%

0.28%

0.44%

Full year

Total

864,164

963,954 1,086,988

0.28%

0.28%

0.43%

% Receiving full-year coverage

82.8%

84.3%

87.5%

Multiple plans

16,659

16,873

14,992

1.86%

2.51%

4.34%

MA plan coverage = Single plan

162,660

162,956

140,990

3.20%

3.41%

5.95%

Partial year

Total

179,319

179,829

155,982

3.08%

3.33%

5.79%

% Receiving full-year coverage

17.2%

15.7%

12.5%

Multiple plans

96,579

111,083

125,492

0.51%

0.58%

0.87%

Single plan

946,904 1,032,700 1,117,478

0.78%

0.78%

1.13%

All HUD-MA

Total

1,043,483 1,143,783 1,242,970

0.76%

0.76%

1.11%

% Single plan

90.7%

90.3%

89.9%

March 2024

MA Coverage Among HUD-assisted Individuals

36

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

37

What was the most common type of health plan coverage?

Table B.8: Number and Percentage of HUD-MA Individuals and HUD-assisted Properties by Health Plan Type (2018–2020)

Individuals receiving federal housing

HUD-assisted properties with any

MA plan type

assistance and enrolled in MA (HUD-

number of individuals with MA

MA)

coverage

Count

%

Count

%

Distinct Count (2018–2020)

1,500,385

29,972

Health Maintenance Organization

(HMO)

1,083,699

72.2%

27,196

90.7%

HMO point-of-service (HMOPOS)

126,558

8.4%

11,854

39.6%

Local Preferred Provider

Organization (PPO)

201,060

13.4%

19,107

63.7%

Medical Savings Account

88

0.0%

48

0.2%

Private fee-for-service (PFFS) plan

4,747

0.3%

1,724

5.8%

Section 1876 Cost Plan

11,883

0.8%

1,562

5.2%

National Program of All-inclusive

Care for the Elderly (PACE)

18,437

1.2%

3,907

13.0%

Regional Preferred Provider

Organization (PPO)

100,694

6.7%

10,020

33.4%

Medicare-Medicaid Plan (MMP)

HMO

114,200

7.6%

6,374

21.3%

Medicare-Medicaid Plan HMO

Point-of-Service (MMP HMOPOS)

120

0.0%

68

0.2%

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Individuals were counted as enrolled in a type of MA plan if the individual was enrolled in a plan of that type as of December (or the latest MA enrollment month) in a calendar year. Individuals may be enrolled in different types of MA plans or move properties across years.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

38

Figure B.1: MA Plan Parent Organizations with the Largest Proportions of HUD-MA Individuals UnitedHealth Group, Inc.

Humana Inc.

Anthem Inc.

Centene Corporation

Healthfirst, Inc.

Aetna / CVS Health Corporation

Kaiser Foundation Health Plan, Inc.

CIGNA

Molina Healthcare, Inc.,

EmblemHealth, Inc.

WellCare Health Plans, Inc.

2018

2019

2020

0%

5%

10%

15%

20%

25%

30%

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

What proportion of HUD-assisted individuals with Medicare Advantage coverage also had

Medicaid coverage? Did it vary by HUD program category?

Table B.9: Proportion of HUD-MA Individuals with Full-Benefit Medicaid Coverage, by HUD Program Category (2018-2020)

HUD program category

Full Medicaid Coverage during

Full Medicaid Coverage for all

any month of MA coverage (%)

MA coverage period (%)

2018

2019

2020

2018

2019

2020

Project-based Section 8 (PBS8)

62.3

63.7

64.5

45.1

47.2

51.5

Public housing

76.5

76.8

77.6

55.9

57.8

61.9

Section 202 for older adults

51.6

52.8

53.3

39.1

41.0

44.1

Section 811 for individuals with disabilities

73.7

74.8

75.2

53.8

55.5

60.4

Vouchers

88.3

87.8

87.8

62.8

64.4

69.1

Other

71.2

73.7

75.2

51.4

54.6

59.9

Overall

75.0

75.6

76.2

54.1

56.0

60.5

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Full-benefit Medicaid coverage was identified based on DUAL_ELGBL_CD in the CMS MBSF data. Individual was flagged to have full-benefit Medicaid coverage if the indicator had values 02, 04, 08 (Eligible is entitled to Qualified Medicare Beneficiary (QMB) and full Medicaid coverage, including prescription drugs; Eligible is entitled to Medicare-Specified Low-Income Medicare Beneficiary (SLMB) and full Medicaid coverage, including prescription drugs; Eligible is entitled to other dual eligible [Non-QMB, SLMB, Qualified Disabled Working Individual (QDWI), or Qualifying Individual (QI)] with full Medicaid coverage, including prescription drugs, respectively) and had a valid MA plan ID (non-missing) for the month. Denominator for the proportion is the number of individuals receiving specific federal housing assistance program support. Numerator is the number (among denominator) who had full Medicaid coverage during the calendar year.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

39

Table B.10: Proportion of HUD-MA Individuals with Medicare Savings Program (QMB, SLMB, QDWI, or QI) Medicaid Coverage or No Medicaid Coverage, by HUD Program Category (2018–2020)

HUD benefit program

% having QMB / SLMB / QDWI / QI

at any time

% not having Medicaid at any time

2018

2019

2020

2018

2019

2020

Project-based Section 8 (PBS8)

71.0

72.9

73.2

22.9

21.8

21.2

Public housing

69.8

71.3

71.0

21.7

21.3

21.0

Section 202 for older adults

69.1

70.6

70.8

25.3

24.3

23.8

Section 811 for individuals with

disabilities

78.6

80.1

79.7

10.8

9.9

10.0

Vouchers

79.1

80.0

79.9

14.4

14.2

14.0

Other

72.2

74.9

76.3

21.3

19.3

17.5

Overall

73.9

75.4

75.5

19.4

18.7

18.2

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage. QDWI = Qualified Disabled Working Individual. QI

= Qualifying Individual. QMB = Qualified Medicare Beneficiary. SLMB = Specified Low-Income Medicare Beneficiary.

Notes: Denominator is the number of individuals with specific federal housing assistance program support and had an MA plan.

QMB/SLMB/QDWI/QI = Based on DUAL_ELGBL_CD indicator in the CMS MBSF data. Individual was flagged if the indicator had values 01, 02, 03, 04, 05, 06 during any month with valid MA plan coverage (non-missing MA plan ID). Numerator is the number (among denominator) who never had Medicaid during the calendar year (and did not have any of the DUAL_ELGBL_CD [01, 02, 03, 04, 05, 06, 08] during all months with MA coverage).

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

How many HUD-assisted individuals with Medicare Advantage coverage received assistance

through each HUD program category?

Table B.11: Number of Individuals, by HUD Program Category (2018–2020)

HUD program category

2018

2019

2020

2018–2020

Overall

9,513

9,418

9,318

11,648

Section 202 for older

adults

134

134

133

164

Section 811 for

individuals with

35

36

36

46

HUD-assisted individuals (in

disabilities

'000s)

Project-Based

Section 8 (PBS8)

2,038

2,038

2,051

2,717

Other assisted

multifamily

57

49

42

75

Public housing

1,983

1,907

1,822

2,481

Vouchers

5,270

5,258

5,239

6,434

Overall

2,559

2,519

2,455

3,005

Section 202 for older

adults

129

129

127

158

HUD-Medicare individuals (in

Section 811 for

'000s)

individuals with

24

24

23

29

disabilities

Project-Based

Section 8 (PBS8)

789

783

771

951

March 2024

MA Coverage Among HUD-assisted Individuals

40

Other assisted

multifamily

18

15

13

22

Public housing

487

460

428

555

Vouchers

1,112

1,108

1,092

1,290

Overall

1,043

1,144

1,243

1,500

Section 202 for older

adults

67

71

75

93

Section 811 for

individuals with

6

7

8

10

disabilities

HUD-MA individuals (in '000s)

Project-Based

Section 8 (PBS8)

334

365

398

492

Other assisted

multifamily

8

7

7

11

Public housing

216

226

234

299

Vouchers

413

467

521

620

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: A small number of individuals received multiple HUD program benefits during a year. The 2018–2020 column shows distinct counts of individuals across the period. Individuals may receive different program benefits in the three-year time span and have been included (only once) for all relevant programs.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Figure B.2: Distribution of HUD-assisted and HUD-MA Populations, by HUD Program Category (2018–2020) HUD-MA individuals

42%

32%

19%

6%

2020 HUD-assisted individuals

56%

22%

20%

1%

HUD-MA individuals

41%

32%

20%

6%

2019 HUD-assisted individuals

56%

22%

20%

1%

HUD-MA individuals

40%

32%

21%

6%

2018 HUD-assisted individuals

55%

21%

21%

1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Vouchers

Project-Based Section 8 (PBS8)

Public housing

Section 202 for older adults

Section 811 for individuals with disabilities Other assisted multifamily

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: HUD-assisted individuals = Individuals receiving federal housing assistance. HUD-MA individuals = Individuals receiving HUD

assistance with MA coverage.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

41

Figure B.3: Proportion of HUD-assisted Individuals with Medicare Advantage Coverage, by HUD Program Category (2018–2020)

56.7%

60%

50.0% 53.3%

2018

2019

2020

40%

22.3%

17.9% 20.3%

16.4% 17.9% 19.4%

16.4%

20%

11.0% 12.1% 13.3%

13.4% 14.8%

10.9% 11.9% 12.9%

7.8% 8.9% 9.9%

0%

Overall

Section 202 for Section 811 for Project-Based

Other assisted

Public housing

Vouchers

older adults

individuals with Section 8 (PBS8)

multifamily

disabilities

HUD = U.S. Department of Housing and Urban Development.

Notes: For calculation of proportion, denominator is the distinct number of individuals receiving specific HUD benefit program assistance in a year; numerator is, among denominator, the number of individuals who had MA plan coverage in the same year.

A small number of individuals had multiple benefit programs. For this analysis, if an individual received assistance through multiple programs, the individual was included in the denominator for all relevant programs.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Figure B.4: Distribution of HUD-assisted and HUD-MA Populations Ages 65+, by HUD Program Category (2018–2020)

HUD-MA individuals

35%

37%

19%

9%

2020 HUD-assisted individuals

37%

37%

17%

8%

HUD-MA individuals

34%

36%

20%

9%

2019 HUD-assisted individuals

36%

37%

18%

8%

HUD-MA individuals

33%

37%

21%

9%

2018 HUD-assisted individuals

35%

37%

19%

8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Vouchers

Project-Based Section 8 (PBS8)

Public housing

Section 202 for older adults

Section 811 for individuals with disabilities Other assisted multifamily

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: HUD-assisted individuals = Individuals receiving federal housing assistance. HUD-MA individuals = Individuals receiving HUD

assistance with MA coverage.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

42

Figure B.5: Proportion of HUD-assisted Individuals Age 65+ with Medicare Advantage Coverage, by HUD

Program Category (2018–2020)

58.6%

55.8% 59.8%

58.0%

60.0%

53.5%

51.9% 55.3%

53.1%

51.8%

51.9% 54.9%

50.7%

47.2% 50.3%

46.3% 49.5%

44.5% 47.7%

36.5% 39.9%

40.0%

33.1%

20.0%

0.0%

Overall

Section 202 for Section 811 for Project-Based

Other

Public housing

Vouchers

older adults

individuals with Section 8 (PBS8)

disabilities

2018

2019

2020

Notes: For calculation of proportion, denominator is the distinct number of individuals receiving specific HUD benefit program assistance in a year; numerator is, among denominator, the number of individuals who had MA plan coverage in the same year.

A small number of individuals had multiple benefit programs. For this analysis, if an individual had multiple programs, the individual was included in the denominator for all relevant programs.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

43

Figure B.6: Proportion of HUD-assisted Individuals with Reported Hispanic Ethnicity with Medicare Advantage Coverage, by HUD Program Category (2018–2020)

100%

80%

2018

2019

2020

69.5%

64.3% 67.2%

60%

40%

22.9% 23.8% 24.7%

17.0% 18.4% 19.5%

15.6% 17.8% 19.5%

20%

8.9% 12.2% 12.7%

9.2% 10.2% 11.2%

0%

Section 202 for Section 811 for

Project-based Other multifamily Public Housing

Vouchers

older adults

individuals with Section 8 (PBS8)

assisted

disabilities

Notes: Hispanic indicator based on ethnicity information captured in HUD longitudinal data.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data

Figure B.7: Proportion of HUD-assisted Individuals with Reported Race as Black or White with Medicare Advantage Coverage, by HUD Program Category (2018–2020)

100%

Black Race

80%

63.1%

2018

2019

2020

55.3% 59.4%

60%

40%

18.9% 21.2% 23.0%

10.9% 12.1% 13.1%

11.1% 12.4% 13.8%

20%

8.6% 9.7% 10.7%

6.1% 6.9% 7.8%

0%

Section 202 for

Section 811 for

Project-based

Other multifamily Public Housing

Vouchers

older adults

individuals with Section 8 (PBS8)

assisted

disabilities

100%

White Race

80%

2018

2019

2020

55.3%

60%

48.9% 51.9%

40%

22.6%

23.5% 25.6%

17.7% 20.3%

21.5%

16.2% 17.7% 19.4%

13.2% 14.2% 15.3%

20%

10.0% 11.4% 12.8%

0% Section 202 for Section 811 for Project-based

Other

Public Housing

Vouchers

older adults individuals with Section 8 (PBS8) multifamily

disabilities

assisted

Notes: Race based on HUD longitudinal data, irrespective of ethnicity, and excludes any individuals who identified multiple races (e.g., White and Black), but White can include White Hispanic and White non-Hispanic.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

How many HUD-assisted properties had HUD-MA individuals?

Table B.12: Number of HUD-assisted Properties (2018–2020)

Property Type

2018

2019

2020

Properties with HUD-assisted individuals

31,720

30,313

30,114

Ages 62+

29,369

28,473

28,343

March 2024

MA Coverage Among HUD-assisted Individuals

44

Property Type

2018

2019

2020

Ages 65+

28,397

27,627

27,573

With Medicare coverage

31,028

29,889

29,716

With Medicare Advantage (MA) coverage

26,673

26,562

26,974

Properties with HUD-assisted individuals and two or more MA plans

19,887

20,527

21,605

Ages 62+

17,643

18,300

19,347

Ages 65+

17,030

17,626

18,669

Properties with more than 10 HUD-assisted individuals with MA

coverage

14,504

15,374

16,249

Ages 62+

12,404

13,089

13,849

Ages 65+

11,779

12,386

13,134

Properties with more than 10 HUD-assisted individuals with MA

coverage and two or more MA plans

13,664

14,522

15,589

Ages 62+

11,685

12,378

13,305

Ages 65+

11,090

11,732

12,626

Properties with more than 10 HUD-assisted individuals with MA

coverage and only one MA plan

840

852

660

Ages 62+

719

711

544

Ages 65+

689

654

508

Notes: Across all three study years (2018–2020), HUD-assisted individuals of any age resided in a total of 33,759 HUD-assisted properties. Properties associated with receiving federal housing assistance (HUD-assisted properties) were identified using a combination of three fields (development number and project number and name) captured in the HUD longitudinal data.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Figure B.8: Proportion of Individuals Residing in HUD-assisted Properties with More Than 10 Residents with MA Coverage, by HUD Program Categorya, b (2018–2020)

80%

Section 202 for older adults

Section 811 for individuals with disabilities

70%

Project-Based Section 8 (PBS8)

Other assisted multifamily

Public housing

Vouchers

60%

50%

20.7%

19.8%

18.8%

40%

20.8%

20.2%

19.5%

30%

31.9%

31.9%

31.9%

20%

21.3%

21.6%

21.9%

10%

0.5%

0.5%

0.3%

0.5%

6.4%

0.3%

6.2%

0.3%

6.0%

0%

1.4%

1.4%

1.4%

HUD-assisted

HUD-MA

HUD-assisted

HUD-MA

HUD-assisted

HUD-MA

individuals

individuals

individuals

individuals

individuals

individuals

2018

2019

2020

March 2024

MA Coverage Among HUD-assisted Individuals

45

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: HUD-assisted individuals = Individuals receiving federal housing assistance. HUD-MA individuals = Individuals receiving HUD

assistance with MA coverage. Denominator for HUD-assisted individuals is all individuals receiving federal housing assistance.

Denominator for HUD-MA individuals is all HUD-assisted individuals with MA coverage. (a) Individuals living in a property receiving federal housing assistance only received benefits from the following HUD programs: public housing assistance Project-Based Section 8, Section 101 (Rent Supplement), Rental Assistance Program, Section 236, Section 221, Section 202, Section 811, Section 202/162. (b) Proportions for HUD program categories Other Assisted Multifamily and Vouchers round to 0% and are not visible in the graph.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

What proportion of HUD-assisted property residents had partial-year federal housing

assistance?

Table B.13: Individuals Receiving Federal Housing Assistance, by Partial Year Status (2018–2020) Year Status

2018

2019

2020

Full-year participants in the

same property

3,960,541

3,884,610

3,829,571

Full-year participants in

HUD-assisted individuals

multiple properties

2,415

1,790

1,628

Partial-year participants

303,997

299,495

273,457

% Partial year

7.1%

7.2%

6.7%

Portability move-in (vouchers

Reason for partial-year

only)

60,409

59,164

55,371

participation

Move-in certification

243,595

240,337

218,094

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Does the number of MA plans with enrollees residing in a property vary?

Table B.14: Number of HUD-assisted Properties and HUD-assisted Individuals Ages 65+ with MA Coverage by Number of MA Plans Present at a Property (2018–2020)

Number of

Number of HUD-assisted

Number of individuals ages 65+

MA plans

Number of HUD-assisted

properties with >10 residents

in HUD-assisted properties with

per property

properties with >10 residents

with MA coverage

>10 residents with MA coverage

2018

2019

2020

2018

2019

2020

2018

2019

2020

1

5,618 4,943 4,205

840

852

660

10

9

6

2

6,634 6,381 6,466

2,879

2,862 3,043

52

45

49

3

5,176 5,491 5,705 3,470

3,848 4,112

72 81 83

4

3,711 3,981 4,202 3,226 3,542 3,698

90 99 102

5

2,166 2,530 2,686 2,068 2,443 2,590

76 92 99

6

1,248 1,162 1,335 1,238 1,152 1,323

60 64 71

7

469

458

542 467 456 539

36 35 38

8

107

127

189 107 127 189

15 18 22

9

33 36 57 33 36 57

9

11

14

10+

13 12 15 13 12 15

5

4

6

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: HUD properties were identified by state using project or development number. Some properties can be in multiple states and have been counted as separate properties for this analysis.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

46

Were there geographic concentrations of HUD-MA individuals?

Figure B.9: States with the Largest Proportions of HUD-assisted and HUD-MA Individuals (2020) 15%

% Among HUD-Assisted

% Among HUD-Medicare

10%

% Among HUD-MA

5%

0%

NY CA

FL

TX

PA OH MA NJ

IL

GA MI TN NC WA VA MN MO WI

AL

LA

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Figure B.10: Number of HUD-assisted Individuals (in Thousands), by State (2020) HUD = U.S. Department of Housing and Urban Development.

Notes: This map depicts the number of HUD-assisted indiviudals (in thousands) in each state in the contiguous United States. Alaska and Hawaii are not shown. In 2020, approximately 15,000 HUD-assisted individuals resided in Alaska, and approximately 48,000

HUD-assisted individuals resided in Hawaii.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

47

Figure B.11: Number of HUD-assisted Individuals (in Thousands), by County (2020) HUD = U.S. Department of Housing and Urban Development.

Notes: This map depicts the number of HUD-assisted indiviudals (in thousands) in each county in the contiguous United States.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Figure B.12: Number of HUD-assisted Individuals Ages 65+ (in Thousands), by State (2020)

HUD = U.S. Department of Housing and Urban Development.

Notes: This map depicts the number of HUD-assisted indiviudals ages 65 and older (in thousands) in each state in the contiguous United States. Alaska and Hawaii are not shown. In 2020, approximately 2,000 HUD-assisted individuals ages 65 and older resided in Alaska, and approximately 8,000 HUD-assisted individuals ages 65 and older resided in Hawaii.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

48

Figure B.13: Number of HUD-assisted Individuals Ages 65+ (in Thousands), by County (2020) HUD = U.S. Department of Housing and Urban Development.

Notes: This map depicts the number of HUD-assisted indiviudals ages 65 and older (in thousands) in each county in the contiguous United States.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Figure B.14: Number of HUD-MA Individuals Ages 65+ (in Thousands), by State (2020) HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: Alaska and Hawaii are not shown. In 2020, 20 HUD-MA individuals ages 65 and older resided in Alaska, and approximately 6,000 HUD-MA individuals ages 65 and older resided in Hawaii.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

49

Figure B.15: Number of HUD-MA Individuals Ages 65+ (in Thousands), by County (2020) HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Notes: This map depicts the number of HUD-MA indiviudals ages 65 and older (in thousands) in each county in the contiguous United States.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

Table B.15: Proportion of HUD-assisted Individuals Residing in a Metropolitan Statistical Area (MSA) (2018–

2020)

Type of Individual

2018

2019

2020

In MSA

18.5

18.7

18.9

HUD-assisted individuals (%) Not in MSA

5.5

5.5

5.5

Unknown

76.0

75.8

75.5

In MSA

33.7

33.3

32.8

HUD-MA individuals (%)

Not in MSA

5.8

6.1

6.3

Unknown

60.5

60.7

60.9

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage. MSA = metropolitan statistical area.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

50

Figure B.16: Proportion of HUD-MA Individuals Receiving Public Housing and Assisted Multifamily Assistance, by State (2020)

100%

80%

60%

40%

20%

.9)

I (32.)

(8

(6.4)

Y (.2)

A (50.1)

I (21.5)

D (9.5)

S (8.8)

E (7.4)

V (6.2)

T (1.6)

NJ (44.9) IL (38.)

A (27.4)

N (21.8) O (21.8)

IA (9.1) OK M HI (7.7) M KS (6.7)

W UT (5.6) NE (5.2) DC (5.2) NV (4.3) NH (4.3) ID (3.4) DE (2.5) M SD (1.5) VT (1.1) ND (1.1) W

NY (182.3) CA (105.8) FL (73.4) TX (72.1) PA (70.4) OH (56.8) M

GA (33.4) M TN (30.7) NC (29.) W VA (22.4) M M W AL (20.6) LA (20.5) CT (20.2) IN (17.5) KY (16.8) RI (16.2) OR (15.5) SC (15.4) CO (15.2) AZ (15.) AR (11.7) M

NM

HUD = U.S. Department of Housing and Urban Development. MA = Medicare Advantage.

Sources: Authors’ analysis of HUD longitudinal data and CMS Master Beneficiary Summary File merged data.

March 2024

MA Coverage Among HUD-assisted Individuals

51

REFERENCES

1

U.S. Department of Housing and Urban Development, Office of Policy Development & Research (n.d.). Assisted Housing: National and Local. Picture of Subsidized Housing.

2

The Lewin Group (2014). Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in

HUD-Assisted Housing. Office of the Assistant Secretary for Planning and Evaluation.

3

The Lewin Group (2016). Picture of Housing and Health Part 2: Medicare and Medicaid Use Among Older

Adults in HUD-Assisted Housing, Controlling for Confounding Factors. Office of the Assistant Secretary for Planning and Evaluation.

4

Helms, V. E., Sperling, J., and Steffen, B. L. (2017). A Health Picture of HUD-Assisted Adults, 2006–2012: HUD

Administrative Data Linked With the National Health Interview Survey. Office of Policy Development and Research.

5

Helms, V. E., Sperling, J., and Steffen, B. L. (2017). A Health Picture of HUD-Assisted Adults, 2006–2012: HUD

Administrative Data Linked With the National Health Interview Survey. Office of Policy Development and Research.

6

The Lewin Group (2014). Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in

HUD-Assisted Housing. Office of the Assistant Secretary for Planning and Evaluation.

7

The Lewin Group (2016). Picture of Housing and Health Part 2: Medicare and Medicaid Use Among Older

Adults in HUD-Assisted Housing, Controlling for Confounding Factors. Office of the Assistant Secretary for Planning and Evaluation.

8

The Lewin Group (2014). Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in

HUD-Assisted Housing. Office of the Assistant Secretary for Planning and Evaluation.

9

The Lewin Group (2014). Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in

HUD-Assisted Housing. Office of the Assistant Secretary for Planning and Evaluation.

10

The Lewin Group (2016). Picture of Housing and Health Part 2: Medicare and Medicaid Use Among Older

Adults in HUD-Assisted Housing, Controlling for Confounding Factors. Office of the Assistant Secretary for Planning and Evaluation.

11

The Lewin Group (2016). Picture of Housing and Health Part 2: Medicare and Medicaid Use Among Older

Adults in HUD-Assisted Housing, Controlling for Confounding Factors. Office of the Assistant Secretary for Planning and Evaluation.

12

The Lewin Group (2016). Picture of Housing and Health Part 2: Medicare and Medicaid Use Among Older

Adults in HUD-Assisted Housing, Controlling for Confounding Factors. Office of the Assistant Secretary for Planning and Evaluation.

13

Thompson, T., McQueen, A., Croston, M., Luke, A., Caito, N., Quinn, K., Funaro, J., and Kreuter, M. W. (2019).

Social Needs and Health-Related Outcomes Among Medicaid Beneficiaries. Health Education & Behavior: The Official Publication of the Society for Public Health Education, 46(3), 436–444.

14

Mode, N. A., Evans, M. K., and Zonderman, A. B. (2016). Race, Neighborhood Economic Status, Income

Inequality and Mortality. PLoS ONE, 11(5), e0154535.

15

Braveman, P. A., Cubbin, C., Egerter, S., Williams, D. R., and Pamuk, E. (2010). Socioeconomic Disparities in Health in the United States: What the Patterns Tell Us. American Journal of Public Health, 100(Suppl 1), S186–

S196. https://doi.org/10.2105/AJPH.2009.166082

16

Belle, D., and Doucet, J. (2003). Poverty, Inequality, and Discrimination as Sources of Depression Among U.S.

Women. Psychology of Women Quarterly, 27(2), 101–113. https://doi.org/10.1111/1471-6402.00090

March 2024

MA Coverage Among HUD-assisted Individuals

52

17

Buttorff, C., Ruder, T., and Bauman, M. (2017). Multiple Chronic Conditions in the United States. RAND

Corporation.

18

Ochieng, N., Cubanski, J., Neuman, T., Artiga, S., and Damico, A. (2021). Racial and Ethnic Health Inequities and

Medicare. Kaiser Family Foundation.

19

Helms, V., Sperling, J., and Steffen, B. (2017). A Health Picture of HUD-Assisted Adults, 2006–2012: HUD

Administrative Data Linked With the National Health Interview Survey. Office of Policy Development and Research.

20

Reichard, A., Stolzle, H., and Fox, M. H. (2011). Health Disparities Among Adults with Physical Disabilities or Cognitive Limitations Compared to Individuals with No Disabilities in the United States. Disability and Health Journal, 4(2), 59–67. https://doi.org/10.1016/j.dhjo.2010.05.003

21

The Lewin Group (2012). The “Value Added” of Linking Publicly Assisted Housing for Low-Income Older Adults

with Enhanced Services: A Literature Syntheses and Environmental Scan. Office of the Assistant Secretary for Planning and Evaluation.

22

Kandilov, A., et al. (2019). Support and Services at Home (SASH) Evaluation: Highlights from the Evaluation of

Program Outcomes from 2010 to 2016. Office of the Assistant Secretary for Planning and Evaluation.

23

Centers for Medicare & Medicaid Services (2018). Reinterpretation of “Primarily Health Related” for

Supplemental Benefits.

24

Centers for Medicare & Medicaid Services (n.d.). CMS Program Statistics – Medicare Total Enrollment.

25

Centers for Medicare & Medicaid Services (n.d.). Access to Health Coverage.

26

Centers for Medicare & Medicaid Services (2018). Reinterpretation of “Primarily Health Related” for

Supplemental Benefits.

27

Centers for Medicare & Medicaid Services (2019). Implementing Supplemental Benefits for Chronically Ill

Enrollees.

28

ATI Advisory and Long-Term Quality Alliance (2022). Data Insight: Growth in New, Non-Medical Benefits Since

Implementation of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC)

Care Act.

29

Khodyakov, D., et al. (2022). Evaluation of Phase II of the Medicare Advantage Value-Based Insurance Design

Model Test: First Two Years of Implementation (2020-2021). RAND Health Care.

30

Brucker, D., Helms, V., and Souza, T. (2017). Health and Health Services Access Among Adults With Disabilities

Who Receive Federal Housing Assistance. Housing Policy Debate, DOI: 10.1080/10511482.2017.1357048.

31

Ochieng, N., Biniek, J. F., Freed, M., Damico, A., and Neuman, T. (2023). Medicare Advantage in 2023:

Enrollment Update and Key Trends. Kaiser Family Foundation.

32

Freed, M., Biniek, J. F., Damico, A., and Neuman, T. (2022). Medicare Advantage 2023 Spotlight: First Look.

Kaiser Family Foundation.

33

Kaiser Family Foundation (n.d.). Medicare Advantage: Total Enrollment, by Plan Type, 2020.

34

Kaiser Family Foundation (n.d.). Medicare Advantage: Total Enrollment, by Plan Type, 2020.

35

Ochieng, N., Biniek, J. F., Freed, M., Damico, A., and Neuman, T. (2023). Medicare Advantage in 2023:

Enrollment Update and Key Trends. Kaiser Family Foundation.

March 2024

MA Coverage Among HUD-assisted Individuals

53

Document Outline

- Medicare Advantage Coverage Among Individuals Receiving Federal Housing Assistance

- KEY POINTS

- INTRODUCTION

- BACKGROUND

- HUD Assistance Programs

- HUD-Assisted Individuals' Health Status and Health Care Utilization

- Care Coordination and Supportive Services

- Medicare Advantage Supplemental Benefits

- METHODS

- FINDINGS

- Demographic Characteristics of HUD-MA Individuals

- Duration of MA Enrollment Among HUD-assisted Individuals

- Ownership and Types of Medicare Advantage Plan

- HUD Program Categories Through Which HUD-MA Individuals Received Assistance

- HUD-assisted Properties with MA Enrollees

- Geographic Distribution of HUD-MA Individuals

- DISCUSSION

- CONCLUSION

- APPENDIX A: DETAILED METHODOLOGY

- Study Population

- Data

- Data Linkage Methodology

- Analytic Data Preparation Methodology

- Variable Mapping

- MA Plan

- Race

- Federal Housing Assistance Program Categories

- Property Identifier

- Dual Eligible Indicators

- Limitations

- APPENDIX B: DETAILED FINDINGS

- How many individuals received federal housing assistance (HUD-assisted)? Among HUD-assisted individuals, how many had Medicare coverage (HUD-Medicare) and Medicare Advantage coverage (HUD-MA)?

- What proportion of HUD-assisted individuals had Medicare and MA coverage?

- What was the demographic composition of HUD-assisted individuals, including those with Medicare (Traditional and MA and MA-only) coverage?

- Did MA Plan coverage vary by size of household or income?

- Did HUD-MA individuals have MA plan coverage for all 12 months? Did individuals switch plans?

- What was the most common type of health plan coverage?

- What proportion of HUD-assisted individuals with Medicare Advantage coverage also had Medicaid coverage? Did it vary by HUD program category?

- How many HUD-assisted individuals with Medicare Advantage coverage received assistance through each HUD program category?

- How many HUD-assisted properties had HUD-MA individuals?

- What proportion of HUD-assisted property residents had partial-year federal housing assistance?

- Does the number of MA plans with enrollees residing in a property vary?

- Were there geographic concentrations of HUD-MA individuals?

- REFERENCES

Table of Contents

Medicare Advantage Coverage Among Individuals Receiving Federal Housing Assistance

KEY POINTS

INTRODUCTION

BACKGROUND

HUD Assistance Programs

HUD-Assisted Individuals' Health Status and Health Care Utilization

Care Coordination and Supportive Services

Medicare Advantage Supplemental Benefits

METHODS

FINDINGS

Demographic Characteristics of HUD-MA Individuals

Duration of MA Enrollment Among HUD-assisted Individuals

Ownership and Types of Medicare Advantage Plan

HUD Program Categories Through Which HUD-MA Individuals Received Assistance

HUD-assisted Properties with MA Enrollees

Geographic Distribution of HUD-MA Individuals

DISCUSSION

CONCLUSION

APPENDIX A: DETAILED METHODOLOGY

Study Population

Data

Data Linkage Methodology

Analytic Data Preparation Methodology

Variable Mapping

MA Plan

Race

Federal Housing Assistance Program Categories

Property Identifier

Dual Eligible Indicators

Limitations

APPENDIX B: DETAILED FINDINGS

How many individuals received federal housing assistance (HUD-assisted)? Among HUD-assisted individuals, how many had Medicare coverage (HUD-Medicare) and Medicare Advantage coverage (HUD-MA)?

What proportion of HUD-assisted individuals had Medicare and MA coverage?

What was the demographic composition of HUD-assisted individuals, including those with Medicare (Traditional and MA and MA-only) coverage?

Did MA Plan coverage vary by size of household or income?

Did HUD-MA individuals have MA plan coverage for all 12 months? Did individuals switch plans?

What was the most common type of health plan coverage?

What proportion of HUD-assisted individuals with Medicare Advantage coverage also had Medicaid coverage? Did it vary by HUD program category?

How many HUD-assisted individuals with Medicare Advantage coverage received assistance through each HUD program category?

How many HUD-assisted properties had HUD-MA individuals?

What proportion of HUD-assisted property residents had partial-year federal housing assistance?

Does the number of MA plans with enrollees residing in a property vary?

Were there geographic concentrations of HUD-MA individuals?

REFERENCES