[Federal Register Volume 63, Number 222 (Wednesday, November 18, 1998)]
[Notices]
[Pages 64137-64139]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-30873]


=======================================================================
-----------------------------------------------------------------------

SOCIAL SECURITY ADMINISTRATION


Demonstration to Improve Enrollment in State Buy-in to Medicare 
for Low-Income Medicare Beneficiaries

AGENCY: Social Security Administration.

ACTION: Notice, request for comments and solicitation for demonstration 
participation by States.

-----------------------------------------------------------------------

SUMMARY: Title IV of Division A, Social Security Administration, of the 
Omnibus Consolidated and Emergency Supplemental Appropriations Act, 
1999, Public Law 105-277, directs the Commissioner of Social Security 
to expend $6,000,000 for Federal-State partnerships which will evaluate 
means to promote the Medicare buy-in programs targeted to elderly and 
disabled individuals under titles XVIII and XIX of the Social Security 
Act (the Act). Administration of the Medicare buy-in programs described 
in titles XVIII and XIX of the Act is the responsibility of the 
Administrator of the Health Care Financing Administration (HCFA) in the 
Department of Health and Human Services. The Commissioner of Social 
Security is responsible for the Social Security and Supplemental 
Security Income (SSI) programs described in titles II and XVI of the 
Act.
    The Medicare and Medicaid programs are statutorily linked to the 
programs administered by the Social Security Administration (SSA). 
Because of this linkage, SSA provides certain Medicare- and Medicaid-
related services to HCFA, the States and to SSA's beneficiaries. Among 
these services are public service information activities about the 
Medicare and Medicaid programs, categorically needy Medicaid 
eligibility determinations in most States and referral activities for 
certain Medicaid benefits in all States. The scope of SSA's involvement 
in the Medicare and Medicaid programs is defined in the Act and in 
agreements between SSA and HCFA and between SSA and the States.
    The demonstration project specified in Public Law 105-277 will 
assist SSA's low-income disabled beneficiaries and beneficiaries age 65 
and over who are or could be eligible for Medicaid benefits to help pay 
their Medicare costs. SSA intends to work with HCFA to identify and 
investigate barriers and to foster enrollment of those beneficiaries in 
the Medicare buy-in programs. SSA is requesting public comment about 
these plans and soliciting States to express their interest in 
participating in this demonstration.

DATES: Interested persons are invited to submit comments on or before 
December 18, 1998. States interested in participating in this 
demonstration should submit expressions of interest on or before 
December 18, 1998 to the address below.

ADDRESSES: Written comments and expressions of State interest in 
participation should be addressed to Craig A. Streett, Office of 
Program Benefits, Social Security Administration, 6401 Security 
Boulevard, Room 3-M-1 Operations Building, Baltimore, MD 21235, or 
should be electronically mailed to the internet address 
Craig.S[email protected], or should be faxed to 410-966-0980. All comments 
and expressions of State interest in participation received at the 
internet address will be acknowledged by electronic mail to confirm 
receipt.


[[Page 64138]]


FOR FURTHER INFORMATION CONTACT: Craig A. Streett, (410) 965-9793. 
Individuals who use a telecommunications device for the deaf (TDD) may 
call 1-410-966-5609 between 7:00 AM and 7:00 PM, Eastern Time, Monday 
through Friday.

SUPPLEMENTARY INFORMATION: Section 226 of the Act [42 U.S.C. 426] 
describes the rules for entitlement to Medicare Hospital Insurance (HI) 
benefits, also known as Medicare Part A. Generally, Social Security 
beneficiaries who have attained age 65 are entitled to Medicare Part A 
benefits without filing an application or other request for those 
benefits, as are disabled beneficiaries who have received 24 
consecutive months of Social Security benefits. Under section 226A of 
the Act [42 U.S.C. 426-1], certain individuals who suffer from end 
stage renal disease can also become entitled to Medicare HI benefits. 
Some individuals may also be entitled to Medicare HI benefits through 
purchase under the rules in sections 1818 and 1818A of the Act [42 
U.S.C. 1395i-2 and 1395i-2a].
    Section 1840 of the Act [42 U.S.C. 1395s] describes the rules for 
purchase of Medicare Supplementary Medical Insurance (SMI) benefits, 
also known as Medicare Part B. Generally, Medicare Part B benefits will 
begin when Medicare Part A benefits begin unless the beneficiary 
declines the Part B benefits. Usually the beneficiary is responsible 
for the payment of a monthly premium for Medicare Part B benefits. 
Section 1843 of the Act [42 U.S.C. 1395v] describes the agreements 
States may enter into to purchase SMI benefits for some individuals. 
The purchase of SMI benefits by a State for an individual is referred 
to as ``Medicare Part B buy-in.''
    Section 1902(a)(10)(E) of the Act [42 U.S.C. 1396a(a)(10)(E)] 
requires each State's plan for medical assistance to provide for 
Medicare cost-sharing (including Medicare Part B buy-in) for certain 
groups of low-income individuals. Some of the groups of low-income 
individuals are:
    1. Qualified Medicare beneficiaries (QMBs). QMBs are individuals 
who are eligible for Medicaid payment of their Medicare premiums, 
deductibles and coinsurance. QMBs must be entitled to Medicare HI 
benefits (through their own entitlement or by purchase). QMBs must also 
have income that does not exceed the Federal poverty level (FPL) after 
application of the SSI income exclusions, and have resources with 
values that do not exceed twice the SSI standards after application of 
the SSI resources exclusions.
    2. Specified low-income Medicare beneficiaries (SLMBs). SLMBs are 
Medicare beneficiaries who would be QMBs but for income which exceeds 
the FPL but is less than 120 percent of the FPL after application of 
the SSI income exclusions. SLMBs are eligible for Medicare Part B buy-
in.
    3. Qualified individuals--1 (QI-1s). Subject to the availability of 
funding, QI-1s are Medicare beneficiaries who would be QMBs or SLMBs 
but for income which exceeds the allowable limit but is less than 135 
percent of the FPL after application of the SSI income exclusions. QI-
1s are eligible for Medicare Part B buy-in.
    For most Medicare beneficiaries, Medicare entitlement is an 
automatic result of Social Security entitlement when other statutory 
factors of Medicare eligibility are met. Thus, most Medicare 
beneficiaries also are beneficiaries of the Social Security program 
administered by SSA. Because of the linkage between Medicare 
entitlement and Social Security entitlement in title II of the Act and 
the duties of the Commissioner of SSA in title VII of the Act, both SSA 
and HCFA have Medicare entitlement responsibilities. In addition, SSA 
performs additional enrollment and other Medicare-related activities 
under the auspices of agreements between HCFA and SSA.
    Many States have entered into agreements with SSA for SSA to make 
categorically needy Medicaid eligibility determinations for the State's 
SSI beneficiaries under the authority in section 1634 of the Act [42 
U.S.C. 1383c]. Acting on behalf of States with such agreements, SSA 
processes Medicare Part B buy-in for SSI beneficiaries who are eligible 
for this assistance under the rules in section 1843 of the Act.
    Although Medicare entitlement usually is a product of the Social 
Security entitlement process, Medicare Part B buy-in eligibility 
determinations are a Medicaid process. Under title XIX of the Act, 
Medicaid is State-administered under the terms of State plans approved 
by HCFA. SSA plays only a limited role in qualifying individuals for 
Medicare Part B buy-in. SSA does make some buy-in decisions in certain 
States, but only for SSI beneficiaries. SSA also publicizes the 
availability of the Medicare Part B buy-in programs in its field 
offices and through the SSA toll-free number, 1-800-SSA-1213.
    A lack of awareness about the Medicare Part B buy-in programs 
appears to be one of the major obstacles to enrollments. Other 
obstacles to enrollments have also been suggested, including the 
confusion of potential eligibles as to how to apply for these programs 
and a preference for dealing with SSA field offices rather than with 
local welfare offices.
    Because of the low enrollments in the Medicare Part B buy-in 
programs, SSA will conduct a Medicare Part B buy-in demonstration to 
assist our beneficiaries. The two-part demonstration will be designed 
to identify and overcome the obstacles to Medicare Part B buy-in 
enrollments for QMBs, SLMBs and QI-1s. Conferring with HCFA, SSA 
intends to implement both internal and external components of the 
demonstration, and SSA invites States to form Federal-State 
partnerships with SSA to participate in this demonstration.
    As currently envisioned, the internal component of the 
demonstration would involve increased Medicare Part B buy-in referral 
activities by SSA employees when contacted by Medicare-entitled 
beneficiaries. An example of this type of increased referral activities 
may be eligibility screening and subsequent direct notification of 
Medicaid State agencies when a Social Security beneficiary appears to 
be potentially eligible for Medicare Part B buy-in. Currently, SSA 
suggests that beneficiaries get in touch with the Medicaid State agency 
to discuss eligibility for Medicare Part B buy-in without identifying 
those beneficiaries to the State.
    Medicare-entitled Social Security beneficiaries routinely contact 
SSA for a number of reasons, such as reports of the death of a spouse. 
When informed of a spouse's death, SSA recomputes the widow(er)'s 
benefit to determine if the widow(er) might be entitled to a larger 
monthly benefit. In all States, SSA could use these contacts to screen 
carefully for potential Part B buy-in eligibility and both refer the 
caller to the Medicaid State agency and provide identifying information 
about potential Medicare Part B buy-in eligibility to the Medicaid 
State agency for State-initiated followup.
    The external component of the demonstration would involve Federal-
State partnerships. State partners that wish to participate in the 
demonstration would provide ZIP code information that relates to areas 
within each State with a high proportion of low-income aged and 
disabled Medicare beneficiaries who could be eligible but are not 
participating in the Medicare Part B buy-in programs. State 
participants would join with SSA in publicizing this demonstration in 
the targeted communities. Some State partners also would be involved in

[[Page 64139]]

educating SSA employees about the State welfare Medicare buy-in 
application process, and/or providing welfare workers who would be 
assigned to take applications in SSA field offices at certain mutually 
agreeable, fixed times during the demonstration.
    SSA expects to implement the external part of this demonstration in 
no more than 15 communities. That is, SSA and its State partners would 
identify three sets of up to five comparable communities in several 
States. Each set of five comparable communities would be selected to 
participate in each of the following three models:
    1. Screening--Publicity would direct Medicare beneficiaries who may 
be potentially eligible for Medicare Part B buy-in to contact a toll-
free telephone number staffed by SSA employees. SSA staff would perform 
an in-depth Medicare Part B buy-in eligibility screening if at all 
possible while the caller is on the telephone. Potential eligibles 
would then be referred to the local welfare office to file applications 
for benefits, and SSA would track the progress of those applications 
with the State partner.
    2. Co-location--In addition to the publicity and screening efforts 
cited in the preceding model, potential Medicare Part B buy-in 
eligibles also would be invited to file an application for benefits 
with a State welfare worker stationed (for at least some fixed part of 
the week) at the local SSA office.
    3. Application--In addition to the publicity and screening efforts 
cited in the preceding two models, potential Medicare Part B buy-in 
eligibles would be invited to file an application for those benefits, 
completing the appropriate forms with an SSA employee at the local SSA 
office.
    SSA does not envision all three of these models starting at exactly 
the same time. Federal information collection clearance procedures, 
training, logistical details and mutual convenience for both the 
Federal and State partners will dictate starting dates. SSA expects 
these models to end within nine months after implementation.
    SSA intends to employ an independent contractor to consult on the 
design of the demonstration and to conduct an evaluation of the net 
outcomes (e.g., increased applications to and enrollments in the buy-in 
programs) of the demonstrations. The role of the contractor in the 
design phase of the demonstration will be to advise SSA on how to 
implement the three models described above. SSA will be responsible for 
collecting data, and SSA will develop a management information system. 
The contractor will assist SSA and the States in specifying key data 
elements to enhance data comparability across sites. This system may 
include existing SSA administrative data as well as data collected 
through the demonstration. Designs that the contractor will consider 
include both experimental and nonexperimental approaches. An 
experimental design might involve a random assignment of cases to 
treatment and control groups, while a nonexperimental design could 
include the collection of analogous data from comparison sites. Each 
has important implications for the implementation of the three models 
and for the development of the management information system. State 
partners will be expected to cooperate with the contractor at key 
points of the design and evaluation activities. The contractor will be 
expected to consult with HCFA on its activities. Both the internal and 
external components of this demonstration will be designed to avoid 
duplicating any other Federal efforts.
    The evaluation component will include analyses of the relative 
effectiveness of the three models in terms of increasing Medicare Part 
B buy-in applications from the eligible population and increasing 
enrollments in the buy-in programs. The evaluation also will include a 
comparison of buy-in program applications and enrollments under the SSA 
interventions versus HCFA publicity efforts. An appropriate design is 
critical to proper measurement of increases in Medicare Part B buy-in 
enrollments.
    SSA invites the public to comment on its proposed demonstration 
design. SSA also invites States to express interest in participating in 
this demonstration. State partners in the demonstration may be asked to 
implement any or all of the models described above; however, if a State 
that wishes to participate would prefer participation in less than all 
three models, those preferences will be honored to the extent possible.

    Authority: Division A, Title IV of Public Law 105-277.

    Dated: November 13, 1998.
Kenneth S. Apfel,
Commissioner of Social Security.
[FR Doc. 98-30873 Filed 11-17-98; 8:45 am]
BILLING CODE 4190-29-P