Medicare Savings Programs: Results of Social Security
Administration's 2002 Outreach to Low-Income Beneficiaries
(26-MAR-04, GAO-04-363).
To assist low-income beneficiaries with their share of premiums
and other out-of-pocket costs associated with Medicare, Congress
has created four Medicare savings programs. Historic low
enrollment in these programs has been attributed to several
factors, including lack of awareness about the programs, and
cumbersome eligibility determination and enrollment processes
through state Medicaid programs. Concerned about this low
enrollment, Congress passed legislation as part of the Medicare,
Medicaid, and SCHIP Benefits Improvement and Protection Act of
2000 (BIPA) requiring the Social Security Administration (SSA) to
notify low-income Medicare beneficiaries of their potential
eligibility for Medicare savings programs. The statute also
required GAO to study the impact of SSA's outreach effort. GAO
examined what outreach SSA undertook to increase enrollment, how
enrollment changed following SSA's 2002 outreach, and how
enrollment changed in selected states following SSA's outreach
and what additional outreach efforts these states undertook. GAO
reviewed information obtained from SSA and the Centers for
Medicare & Medicaid Services (CMS), analyzed enrollment data
provided by SSA and CMS, and interviewed officials in and
obtained data from six selected states (Alabama, California,
Louisiana, New York, Pennsylvania, and Washington).
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-04-363
ACCNO: A09585
TITLE: Medicare Savings Programs: Results of Social Security
Administration's 2002 Outreach to Low-Income Beneficiaries
DATE: 03/26/2004
SUBJECT: Beneficiaries
Disadvantaged persons
Eligibility criteria
Eligibility determinations
Government information dissemination
Health care programs
Health insurance
Mailing lists
State-administered programs
Managed health care
Medicare Program
Medicare Qualified Disabled and Working
Individual Program
Medicare Qualifying Individuals Program
Qualified Medicare Beneficiary Program
Specified Low Income Medicare
Beneficiary Program
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GAO-04-363
United States General Accounting Office
GAO
Report to Congressional Committees
March 2004
MEDICARE SAVINGS PROGRAMS
Results of Social Security Administration's 2002 Outreach to Low-Income
Beneficiaries
GAO-04-363
Highlights of GAO-04-363, a report to congressional committees
To assist low-income beneficiaries with their share of premiums and other
out-of-pocket costs associated with Medicare, Congress has created four
Medicare savings programs. Historic low enrollment in these programs has
been attributed to several factors, including lack of awareness about the
programs, and cumbersome eligibility determination and enrollment
processes through state Medicaid programs. Concerned about this low
enrollment, Congress passed legislation as part of the Medicare, Medicaid,
and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) requiring
the Social Security Administration (SSA) to notify low-income Medicare
beneficiaries of their potential eligibility for Medicare savings
programs. The statute also required GAO to study the impact of SSA's
outreach effort. GAO examined what outreach SSA undertook to increase
enrollment, how enrollment changed following SSA's 2002 outreach, and how
enrollment changed in selected states following SSA's outreach and what
additional outreach efforts these states undertook.
GAO reviewed information obtained from SSA and the Centers for Medicare &
Medicaid Services (CMS), analyzed enrollment data provided by SSA and CMS,
and interviewed officials in and obtained data from six selected states
(Alabama, California, Louisiana, New York, Pennsylvania, and Washington).
www.gao.gov/cgi-bin/getrpt?GAO-04-363.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kathryn G. Allen at (202)
512-7118.
March 2004
MEDICARE SAVINGS PROGRAMS
Results of Social Security Administration's 2002 Outreach to Low-Income
Beneficiaries
In response to a statutory requirement, SSA is carrying out an annual
outreach effort to help increase enrollment in Medicare savings programs.
This outreach effort consists of mailing letters to potentially eligible
lowincome beneficiaries nationwide as well as sharing data with states to
assist with their supplemental outreach efforts. In 2002, SSA sent 16.4
million letters to low-income Medicare beneficiaries whose incomes from
Social Security and certain other federal sources met the income
eligibility criteria for Medicare savings programs. The 2002 letters
provided eligibility criteria for programs in the beneficiary's home state
and urged beneficiaries interested in enrolling to call a state telephone
number provided. In addition to sending these letters, SSA provided states
with a data file containing information on the beneficiaries to whom it
sent letters. In 2003, SSA sent another 4.3 million letters to potentially
eligible beneficiaries, and indicated that it intends to repeat the
outreach mailing annually to newly eligible beneficiaries and a portion of
prior letter recipients.
Following SSA's outreach efforts in 2002, GAO estimated that more than
74,000 additional eligible beneficiaries enrolled in Medicare savings
programs, 0.5 percent of all 2002 letter recipients, than would have
likely enrolled without the letter. CMS enrollment data also showed that
growth in Medicare savings programs enrollment for the year following
SSA's mailing was nearly double that for each of the 3 prior years. Of the
74,000 additional enrollees, certain states and demographic groups had
somewhat larger increases in enrollment than other groups. The highest
additional enrollment increase was in Alabama, where 2.9 percent of letter
recipients enrolled, followed by Delaware at 2.0 percent. Beneficiaries
less than 65 years old, persons with disabilities, racial and ethnic
minorities, and residents in southern states also had higher enrollment
rates than other groups.
The percentage of letter recipients newly enrolling in Medicare savings
programs following SSA's 2002 mailing ranged from 0.3 to 2.9 percent among
the six states GAO reviewed. The varying effects on enrollment by state
could be attributable to several factors, including the share of eligible
beneficiaries enrolled in Medicare savings programs prior to the outreach,
each state's ability to handle increased call and application volume, and
a state's income and asset limits. Four states GAO reviewed reported
increases in the numbers of calls received or applications mailed or
received following the SSA mailing and then decreases after the mailing
period ended. Each of the states GAO reviewed reported that the state or
other stakeholders conducted additional outreach during SSA's 2002
outreach.
SSA generally agreed with GAO's findings. CMS stated that it did not have
specific comments on the report.
Contents
Letter
Results In Brief
Background
SSA Is Conducting an Annual Outreach Effort Targeted to Low-
Income Medicare Beneficiaries Medicare Savings Program Enrollment
Increased by More than 74,000 Beneficiaries Following the 2002 SSA Mailing
Enrollment Increases Varied among Selected States We Reviewed, with
Several Reporting Increased Calls and Applications Concurrent with SSA
Mailing
Agency and State Comments
1
3 5
12
16
20 25
Appendix I Methodology
Appendix II SSA 2002 Outreach Letter
Appendix III Medicare Savings Program Enrollment following 2002 SSA
Mailing by State
Appendix IV Medicare Savings Program Enrollment following 2002 SSA Mailing
by Demographic Group
Appendix V Comments from the Social Security Administration
Related GAO Products 40
Tables
Table 1: Medicare Coverage and Beneficiary Cost Sharing for 2003 6 Table
2: Medicaid and Medicare Savings Programs' Eligibility
Criteria and Benefits for Low-Income Medicare
Beneficiaries, 2003 9
Table 3: Enrollment in Medicare Savings Programs by Sample
Cohort, December 2002 18 Table 4: Medicare Savings Program Enrollment, May
1999 to May
2003 19 Table 5: Increase in Enrollment following SSA's Outreach to
Targeted Population in Six Selected States, December 2002 20 Table 6:
Average Monthly Calls and Applications Related to
Medicare Savings Programs for Four States prior to,
during, and/or after SSA's Mailing Outreach, January 2002
to April 2003 23
Figures
Figure 1: Medicare Savings Programs Enrollment in Two Sample Cohorts of
SSA Letter Recipients, June 2002 through December 2002 17
Figure 2: Sample 2002 SSA Letter 33
Figure 3: Estimated Percentage Change in Medicare Savings Program
Enrollment Following 2002 SSA Mailing by State, December 2002 35
Figure 4: Estimated Percentage Change in Medicare Savings Program
Enrollment Following 2002 SSA Mailing by Demographic Group, December 2002
37
Abbreviations
BIPA The Medicare, Medicaid, and SCHIP Benefits Improvement
and Protection Act of 2000 CMS Centers for Medicare & Medicaid Services
FPL federal poverty level MBR Master Beneficiary Record QDWI Qualified
Disabled and Working Individuals QI Qualifying Individuals QMB Qualified
Medicare Beneficiaries SLMB Specified Low-Income Medicare Beneficiaries
SSA Social Security Administration SSI Supplemental Security Income
This is a work of the U.S. government and is not subject to copyright
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United States General Accounting Office Washington, DC 20548
March 26, 2004
Congressional Committees
Medicare provides health insurance coverage for a broad array of services,
including hospital, physician, home health, and other services, to more
than 40 million Americans who are elderly, disabled, or have end-stage
renal disease. Medicare beneficiaries pay a portion of the program's costs
through cost-sharing provisions-including premiums, deductibles, and
coinsurance-that can be difficult to afford for low-income beneficiaries.
To assist low-income beneficiaries, Congress has created several Medicare
savings programs that help pay for some or all of Medicare's cost-sharing
provisions. There are four Medicare savings programs, each with differing
income eligibility requirements and levels of benefits-the Qualified
Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary
(SLMB), Qualifying Individual (QI), and Qualified Disabled and Working
Individual (QDWI) programs. To enroll, eligible beneficiaries must have
incomes and assets within the specific program's federal ceilings and
enroll through their state Medicaid program, the joint federal state
program that covers health care services for certain individuals with low
incomes and resources. States may have less restrictive income and asset
requirements that eligible beneficiaries meet to qualify. As of September
2003, about 6.2 million beneficiaries were enrolled in Medicare savings
programs.
We reported in 1999 that 43 percent of beneficiaries eligible for the QMB
and SLMB programs were not enrolled.1 More recent studies also have
reported low enrollment rates.2 Low program enrollment has been attributed
to several factors, including a lack of awareness about the programs,
ineffective outreach, a cumbersome eligibility determination
1U.S. General Accounting Office, Low-Income Medicare Beneficiaries:
Further Outreach and Administrative Simplification Could Increase
Enrollment, GAO/HEHS-99-61, (Washington, D.C.: Apr. 9, 1999).
2See, for example, Kim Glaun, National Senior Citizens Law Center,
Medicaid Programs to Assist Low-Income Medicare Beneficiaries: Medicare
Savings Programs Case Study Findings, prepared for The Kaiser Commission
on Medicaid and the Uninsured, December 2002; and Susan G. Haber et al,
RTI International, Evaluation of Qualified Medicare Beneficiary (QMB) and
Specified Low-Income Medicare Beneficiary (SLMB) Programs, prepared for
the Centers for Medicare & Medicaid Services, October 1, 2003.
and enrollment process that varies among state Medicaid programs, and
perceived stigma among some potentially eligible beneficiaries about
enrolling in a program for low-income people.
Concerned about low enrollment in Medicare savings programs, Congress
passed legislation in 2000 requiring the Social Security Administration
(SSA) to conduct outreach to low-income Medicare beneficiaries to notify
them of their potential eligibility for Medicare savings programs.3 SSA
began notifying beneficiaries in response to the statutory requirement in
2002. The statute also required us to study the impact of SSA's outreach.4
As agreed with the committees of jurisdiction, this report addresses the
following questions:
o What outreach has SSA undertaken to increase enrollment in Medicare
savings programs in response to the statutory requirement?
o How did enrollment in the Medicare savings programs change following
SSA's 2002 outreach to potential beneficiaries?
o How did enrollment in these programs change in selected states
following SSA's outreach, and what outreach efforts did these selected
states also undertake?
To examine SSA's response to the statutory requirement for outreach to
eligible low-income Medicare beneficiaries, we obtained relevant documents
and interviewed officials from SSA and the Centers for Medicare & Medicaid
Services (CMS), the federal agency responsible for administering the
Medicare savings programs. To determine how enrollment in Medicare savings
programs changed following SSA's outreach, we analyzed records from SSA's
Master Beneficiary Record (MBR)-a database that contains the
administrative records of Social Security beneficiaries, including
payments for Medicare premiums-and we report the additional enrollment
following the 2002 SSA outreach that was beyond what would have likely
occurred in the absence of SSA's outreach. We estimated the additional
enrollment increase following the SSA mailing to all letter recipients.5
We analyzed these enrollment changes
3Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of
2000 (BIPA), Pub. L. No. 106-554, App. F, S: 911(a), 114 Stat. 2763,
2763A-583 (adding section 1144 to the Social Security Act; codified at 42
U.S.C. S: 1320b-14 (2000)).
4BIPA S: 911(b), 114 Stat. 2763A-584.
5Throughout this report, we refer to all beneficiaries who were included
in SSA's mailing as "recipients" because past SSA efforts found that only
1.5 percent of letters were returned as undeliverable.
at the national level as well as separately for all states6 and several
demographic groups, such as beneficiaries less than 65 years of age or in
certain minority groups. Any difference in increased enrollment among
state or demographic groups that we report was statistically significant
at a 95 percent confidence level. We also obtained CMS's national
enrollment data for the Medicare savings programs and compared enrollment
trends before and after the SSA outreach. Whereas the SSA MBR data we
analyzed are specific to those beneficiaries who were sent SSA's mailing,
the CMS data also included existing beneficiaries and are not limited to
the beneficiaries who were sent SSA's mailing. To assess how SSA's
outreach affected enrollment in selected states and what outreach efforts
these states undertook, we interviewed officials and collected data from
six states-Alabama, California, Louisiana, New York, Pennsylvania, and
Washington. We selected these states based on several factors, including
their different levels of change in overall Medicare savings programs
enrollment from 2002 to 2003, geographic diversity, relatively large
populations of Medicare savings programs enrollees, and availability of
data on their program enrollment. It was beyond the scope of our work to
examine the effectiveness of any outreach performed by states or CMS
separately from SSA's outreach. In conducting our analyses, we obtained
information from SSA and CMS on reliability checks they made on the data
and any data limitations provided to us, and concluded that their data
were sufficiently reliable for our analysis. Appendix I provides more
detailed information on our methodology. We performed our work from
February 2003 through March 2004 in accordance with generally accepted
government auditing standards.
In response to a statutory requirement in the Medicare, Medicaid, and
SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), SSA is
carrying out an annual outreach effort to help increase enrollment in
Medicare savings programs. This outreach effort consists of mailing
letters to all low-income Medicare beneficiaries nationwide who were not
enrolled in Medicare savings programs at the time the letters were sent as
well as sharing data with states to assist with any state outreach
efforts. From May through November 2002, SSA sent 16.4 million letters to
lowincome Medicare beneficiaries whose incomes from Social Security and
certain other federal sources met the income eligibility criteria for
Medicare savings programs. Because SSA does not have complete
6Throughout this report, we include the District of Columbia in our
discussion of states.
Results In Brief
information on beneficiaries' income and assets, however, many of these
beneficiaries could have had other income or assets that would exceed the
program's eligibility criteria, thus reducing the number of eligible
beneficiaries. The 2002 letters provided eligibility criteria for the
Medicare savings program in the beneficiary's home state and urged
beneficiaries interested in enrolling to call a state telephone number
provided. In addition to sending these letters, SSA provided states with a
data file containing information on the beneficiaries to whom it sent
letters. From June through October 2003, SSA sent 4.3 million letters to
potentially eligible beneficiaries, including beneficiaries newly eligible
for Medicare savings programs as well as a portion of those who had been
sent the 2002 letter but who had not enrolled. SSA indicated that it
intends to annually repeat the outreach mailing to potentially eligible
beneficiaries.
Following SSA's outreach efforts in 2002, we estimated that more than
74,000 additional eligible beneficiaries enrolled in Medicare savings
programs than would have likely enrolled without the letter. This
represents about 0.5 percent of all letter recipients. Further, CMS data
showed that overall enrollment growth in Medicare savings programs
nationwide for the year following SSA's mailing was nearly double each of
the 3 prior years. Thirty-five states had a statistically significant
additional increase in enrollment nationwide following the SSA mailing,
with the largest increases in Alabama (2.9 percent) and Delaware (2.0
percent). Beneficiaries less than 65 years old, persons with disabilities,
racial and ethnic minorities, and residents in southern states had higher
additional enrollment rates than other groups.
Additional enrollment in Medicare savings programs varied significantly
among the six states we reviewed, ranging from 0.3 percent in California,
Washington, and New York to a high of 2.9 percent in Alabama. The varying
effects on enrollment by state could be attributable to several factors,
including the share of eligible beneficiaries already enrolled in Medicare
savings programs prior to the outreach, a state's ability to handle
increased call and application volume, and a state's income and asset
limits. Four states we reviewed reported significant increases in the
numbers of calls received by their hot lines related to Medicare savings
programs and applications mailed or received during the SSA mailing and
then decreases after the SSA mailing period ended. Each of the states we
reviewed reported that the state or other stakeholders, such as community
organizations that advocate for low-income elderly or private health plans
that participated in Medicare, supplemented SSA efforts with additional
outreach that may have also contributed to increased interest and
enrollment in Medicare savings programs.
Background
In commenting on a draft of this report, SSA generally agreed with our
findings and noted that improvements in state enrollment processes could
further increase enrollment. CMS stated that it did not have specific
comments on the report. Louisiana noted that, in comparison to its
experience in 2002, it observed little increase in calls following the
2003 SSA mailing. New York noted that it had a larger increase in Medicare
savings program enrollment overall than we showed in the draft report.
However, we report the increase in enrollment specifically attributable to
the 2002 SSA outreach mailing, not the net increase in enrollment, which
could also be due to factors besides the SSA mailing.
Medicare covers about 40 million elderly (over 65 years old) and disabled
beneficiaries. Individuals who are eligible for Medicare automatically
receive Hospital Insurance, known as part A, which helps pay for inpatient
hospital, skilled nursing facility, hospice, and certain home health
services. A beneficiary generally pays no premium for this coverage unless
the beneficiary or spouse has worked fewer than 40 quarters in his or her
lifetime, but the beneficiary is liable for required deductibles,
coinsurance, and copayment amounts. Medicare-eligible beneficiaries may
elect to purchase Supplementary Medical Insurance, known as part B, which
helps pay for certain physician, outpatient hospital, laboratory, and
other services. Beneficiaries must pay a premium for part B coverage,
which was $58.70 per month in 2003.7 Beneficiaries are also responsible
for part B deductibles, coinsurance, and copayments. Table 1 summarizes
the benefits covered and cost-sharing requirements for Medicare part A and
part B.
7The premium amount is adjusted each year so that expected Medicare
premium revenues equal 25 percent of expected Medicare part B spending. 42
U.S.C. S: 1395r(a) (2000).
Table 1: Medicare Coverage and Beneficiary Cost Sharing for 2003
Part A - Hospital insurance Beneficiary pays
Part A premium No premium if beneficiary or spouse worked at least 40
quarters in lifetime Premium if beneficiary or spouse worked fewer than 40
quarters in lifetime
Inpatient hospital $840 deductible per benefit perioda $210 copayment per
day for days 61-90 $420 copayment per day for days 91-150b All costs
beyond 150 days
Skilled nursing facilityc Nothing for first 20 days Up to $105 copayment
or less per day for days 21-100 All costs beyond 100 days in the benefit
period
Home healthd No cost sharing 20 percent coinsurance for durable medical
equipment
Hospice Up to $5 copayment for outpatient drugs 5 percent coinsurance for
inpatient respite care
Blood Cost of first 3 pints
Part B - Medical insurancee
Part B premium $58.70 per month
Physician and medical $100 deductible each year
20 percent coinsurance for most services
50 percent coinsurance for outpatient mental health
services Clinical laboratory No cost sharing
Home healthd No cost sharing 20 percent coinsurance for durable medical
equipment
Outpatient hospital Coinsurance may vary by service and may exceed 50
percent
Blood Cost of first 3 pints 20 percent coinsurance for additional pints
Source: CMS.
aNo deductible is charged for second and subsequent hospital admissions if
they occur within 60 days of the beneficiary's most recent covered
inpatient stay.
bAfter the first 90 days of inpatient care, Medicare will help pay for an
additional 60 days of inpatient care (days 91-150). Each beneficiary is
entitled to a lifetime reserve of 60 days of inpatient coverage. Each
reserve day may be used only once in a beneficiary's lifetime.
cTo qualify, a Medicare beneficiary must require daily skilled nursing or
rehabilitative therapy services, generally within 30 days of a hospital
stay of at least 3 days in length, and must be admitted to the nursing
home for a condition related to the hospitalization.
dTo qualify for services, beneficiaries must be confined to their homes;
have a plan of care signed by a physician; and need intermittent skilled
nursing care (other than solely venipuncture for the purpose of obtaining
a blood sample), physical therapy, speech-language pathology services, or
have a continuing need for occupational therapy services.
eNo cost sharing is required for certain preventive services, including
specific screening tests for colon, cervical, and prostate cancer, and flu
and pneumonia vaccines.
Many low-income Medicare beneficiaries who cannot afford to pay Medicare's
cost-sharing requirements receive assistance from Medicaid. For Medicare
beneficiaries qualifying for full Medicaid benefits, state Medicaid
programs pay for Medicare's part A (if applicable) and part B cost-sharing
requirements up to the Medicaid payment rate as well as for services that
are not generally covered by Medicare, such as prescription drugs.8 To
qualify for full Medicaid benefits, beneficiaries must meet their state's
eligibility criteria, which include income and asset requirements that
vary by state.9 In most states, beneficiaries that qualify for
Supplemental Security Income (SSI) automatically qualify for full Medicaid
benefits.10 Other beneficiaries may qualify through one of several
optional eligibility categories targeted to low-income beneficiaries,
individuals with high medical costs, or those receiving care at home or in
the community who otherwise would have been institutionalized.
To assist low-income Medicare beneficiaries with their premium and
costsharing obligations, Congress established several Medicare savings
programs-the QMB, SLMB, QI, and QDWI programs. Under these programs, state
Medicaid programs pay enrolled beneficiaries' Medicare premiums. As a
result, for QMB, SLMB and QI beneficiaries, Medicare part B premiums would
not be deducted from their monthly SSA checks. The QMB program also pays
Medicare deductibles and other cost-sharing requirements, thereby saving
beneficiaries from having to make such payments. Beneficiaries eligible
for Medicare savings programs can apply
8Within broad federal guidelines, states have considerable flexibility in
how they administer their Medicaid programs. States administer covered
services under a state Medicaid plan that CMS approves. State Medicaid
programs must cover certain mandatory services, such as physician services
and nursing facility care. While Medicare covers some or all of up to 100
days of skilled nursing facility care following a hospitalization,
Medicaid covers extended nursing facility care. State Medicaid programs
may also cover certain CMS approved optional Medicaid services, such as
prescription drugs. The federal government shares the cost of state
Medicaid expenditures according to a statutory formula, whereby the
federal share ranged from 50 to 77 percent of state Medicaid expenditures
in fiscal year 2003.
9Section 1902(r)(2) of the Medicaid statute provides states flexibility to
use less restrictive or liberalized methodologies than are typically used
for Medicaid in counting applicants' income and resources to expand
eligibility for the Medicare savings program.
10SSI provides cash assistance to aged, blind, and disabled individuals
who have limited income and resources. In 2003, the resource limit was
$2,000 for individuals and $3,000 for couples. SSI resource limits
typically exclude the beneficiary's automobile and house.
for and be determined to be eligible through their state Medicaid
programs. Thirty-three states have agreements with SSA whereby SSA makes
eligibility determinations for a state if beneficiaries are deemed
eligible by SSA to receive SSI benefits.11 In the other 18 states, even if
an individual is eligible to receive SSI benefits, an individual must file
an application with the state or local Medicaid agency to be eligible.
Beneficiaries qualifying for Medicare savings programs receive different
levels of assistance depending on their income. See table 2 for
eligibility criteria and benefits for each program.
11These agreements are made under authority contained in 42 U.S.C. S:
1383c(a) (2000).
Table 2: Medicaid and Medicare Savings Programs' Eligibility Criteria and
Benefits for Low-Income Medicare Beneficiaries, 2003
Program Income eligibility criteriaa,b Benefits
Medicaid Low-income Medicare Optional benefits vary by beneficiaries, as
defined by state, but typically include each state, whose incomes Medicare
part B premiums are up to 100 percent of the and Medicaid services,
federal poverty level including those not covered under Medicare
Medicare savings programs
Qualified Medicare Beneficiary (QMB)
Specified Low-Income Medicare Beneficiary SLMB)
Medicare beneficiaries whose incomes are at 100 percent or less of the
federal poverty level
Medicare beneficiaries whose incomes are above 100 percent but less than
120 percent of the federal poverty level Medicare part Ac (if applicable)
and B premiums, deductibles, and coinsurance paid by state Medicaid
program
Medicare part B premiums paid by state Medicaid program
Medicare part B premiums paid by state Medicaid program
Medicare part A premiums paid by state Medicaid program
Qualifying Individuals (QI)d Medicare beneficiaries whose incomes are at
120 percent but less than 135 percent of the federal poverty level
Qualified Disabled and Disabled and working Working Individuals Medicare
beneficiaries (QDWI)e whose incomes do not
exceed 200 percent of the federal poverty level
Source: CMS.
aIn 2003, the federal poverty level (FPL) per month was $748 for
individuals and $1,010 for couples in the 48 contiguous states and the
District of Columbia. Higher amounts were specified for Alaska and Hawaii.
bStates also have asset limits for individuals to qualify for Medicaid or
Medicare savings programs. These vary by state, but most often for
Medicaid, eligible beneficiaries must have assets no greater than the
limit for SSI, which is $2,000 for individuals and $3,000 for married
couples. SSI resource limits typically exclude the beneficiary's
automobile and house. For Medicare savings programs, eligible
beneficiaries typically must have assets no greater than twice the limit
for SSI.
cMedicare part A premiums are covered under the QMB program for
beneficiaries who worked fewer than 40 quarters.
dUntil December 2002, the QI program, a federal block grant to the states,
consisted of two parts-QI1 and QI-2. The QI-1 program (covering
beneficiaries with incomes at least 120 percent but less than 135 percent
of FPL) and the QI-2 program (covering beneficiaries with incomes at least
135 percent but less than 175 percent of FPL) were originally authorized
through December 2002. The QI-2 program ended as originally provided, but
the QI-1 program was reauthorized through September 2004.
eThese individuals are required to pay part A premiums because they are no
longer entitled to free Medicare part A benefits having successfully
returned to work and exhausted the free Medicare part A benefits available
to them following the end of their disability benefits.
In 1998, Congress passed legislation specifically providing funding for
SSA to evaluate ways to promote Medicare savings programs.12 In response,
SSA conducted demonstration projects to explore the effects of using
various approaches to increase participation in Medicare savings programs.
In one of these demonstrations conducted in 1999 and 2000, SSA tested six
models designed to increase awareness and reduce barriers to enrollment.
The models were implemented at 20 sites in 10 states, as well as the
entire state of Massachusetts. The models differed in the extent to which
SSA was involved in outreach efforts beyond mailing the letters. For
example, in the "application model," SSA staff screened beneficiaries if
they appeared to be eligible, completed applications, collected supporting
documents, and forwarded the completed application form and supporting
evidence to the state Medicaid agency for an eligibility determination. In
the "peer assistance model," Medicare beneficiaries contacted an AARP
toll-free number and were screened for program eligibility by an AARP
volunteer.13 Across all six models, SSA sent more than 700,000 letters
informing low-income Medicare beneficiaries that they may be eligible for
benefits under the Medicare savings programs. The enrollment rate for each
model varied-ranging from an additional 7 enrollees per 1,000 letters to
26 enrollees per 1,000 letters-with the application model recording the
highest enrollment rate and peer assistance recording the lowest.14
In 2000, Congress amended the Social Security Act, through BIPA, requiring
the Commissioner of Social Security to notify eligible Medicare
beneficiaries about assistance available from state Medicaid programs to
help pay Medicare premiums and cost sharing. BIPA also required SSA to
furnish each state Medicaid program with the names and addresses of
individuals residing in the state that SSA determines may be eligible for
12Omnibus Consolidated and Emergency Supplemental Appropriations Act,
1999, Pub. L. No. 105-277, 112 Stat. 2681, 2681-383 (1998).
13AARP, formerly known as the American Association for Retired People, is
an association representing individuals over the age of 50.
14For further information on the six models and the demonstration project
results, see Lisa Maria B. Alecxih et al, Results from the SSA Buy-In
Demonstration: Final Report, prepared by The Lewin Group SSA, October 4,
2001.
the Medicare savings programs. SSA is required to update such information
at least annually.15
In addition to SSA's outreach efforts, CMS and individual states have
engaged in efforts to increase enrollment in Medicare savings programs.
Since fiscal year 2002, CMS has included increasing awareness of the
Medicare savings programs as one of its Government Performance and Results
Act (GPRA) goals.16 Specifically, CMS's goal in fiscal year 2002 was to
develop a baseline to measure awareness of Medicare savings programs and
to set future targets for increasing awareness. CMS estimated that 11
percent of beneficiaries were aware of Medicare savings programs in 2002
and the goal was to increase this to 13 percent for fiscal year 2003. As
part of its efforts to increase awareness, CMS has coordinated with
states, SSA, and other organizations regarding various outreach efforts;
provided information about Medicare savings programs in various CMS
publications; and developed a variety of educational materials for
targeted populations, including minorities. CMS efforts in increasing
enrollment in earlier years included setting state-specific enrollment
targets and measuring progress toward these enrollment targets; developing
and disseminating training and outreach materials to the states, and
sponsoring national and regional training workshops for a variety of
stakeholders, including other federal and state agencies, health care
providers, and community organizations; designing a model application for
Medicare savings programs that states can consider adopting; and providing
grant funding to state Medicaid agencies, state health insurance
assistance programs, and national advocacy groups to test and promote
innovative approaches to outreach.
In 2001, CMS also contracted for a survey of states to identify activities
undertaken to increase program enrollment and streamline administration of
these programs. Some of the most common state efforts included allowing
application by mail (49 states), eliminating in-person interviews (46
states), developing a shorter application form (43 states), and conducting
outreach presentations at health fairs (34 states). Other state efforts
identified by the survey included
1542 U.S.C. S: 1320b-14(b) (2000).
16See CMS, FY 2004 GPRA Annual Performance Plan (Washington, D.C., 2003).
o increasing awareness of the programs through outreach efforts such as
direct mailings and other printed material, and public service
announcements on radio, television, and in newspapers;
o providing training for employees and education for beneficiaries;
o developing partnerships with other entities, such as State Health
Insurance Assistance programs and local agencies on aging, to enhance
outreach efforts and promote issues and solutions involving the Medicare
savings programs;
o eliminating potential barriers to enrollment such as streamlining the
enrollment and renewal process and easing financial eligibility rules;
o supplementing program benefits with other benefits, such as
prescription drug discount programs; and
o providing information targeting underserved populations, including
SSA Is Conducting an Annual Outreach Effort Targeted to Low-Income Medicare
Beneficiaries
minorities.
In response to BIPA, SSA is conducting an annual outreach effort to help
increase enrollment in Medicare savings programs. This outreach consists
of a nationwide mailing campaign and data sharing with the states. SSA
selected low-income Medicare beneficiaries to be sent an outreach letter
if their incomes were below the income eligibility ceilings for the
Medicare savings programs. From May through November 2002, SSA sent a
total of 16.4 million outreach letters to persons potentially eligible for
QMB, SLMB, and QI. Additionally, in late 2002, SSA sent about 53,000
letters to those potentially eligible for benefits under the QDWI program.
Starting in 2003, SSA has targeted annual outreach letters to individuals
newly eligible for Medicare as well as a subset of those who were sent
outreach letters in 2002 but are still not enrolled. From June through
October 2003, SSA sent outreach letters to 4.3 million of these
beneficiaries. SSA intends to continue its outreach mailing annually to
potentially eligible beneficiaries, including recipients who did not
enroll after receiving earlier letters, as well as those whose income has
declined, making them eligible for the program. In addition to sending
outreach letters, in 2002 and 2003 SSA provided states with a data file
that listed residents who were potentially eligible for benefits under the
Medicare savings programs. SSA plans to continue sharing these data once a
year with states. The data provided by SSA could be used by the states to
coordinate their outreach with SSA's or supplement SSA's outreach efforts.
For the 2002 mailing, SSA sent letters three times each week from May
through November. Each time letters were mailed, SSA sent them to
approximately 207,000 Medicare beneficiaries randomly selected from the
16.4 million beneficiaries who were identified as potentially eligible for
QMB, SLMB, and QI.17 Letters were targeted to beneficiaries whose incomes
from Social Security and certain other federal sources were less than 135
percent of the federal poverty level (FPL).18 Specifically, those selected
to be sent the outreach letters were intended to meet the following three
criteria:
o individuals and couples entitled to Medicare, or within 2 months of
Medicare entitlement eligibility;
o individuals who were not currently receiving Medicare savings program
benefits under a state Medicaid program or not already entitled to full
Medicaid based on SSI participation; and
o individuals and couples whose combined Social Security income and
Department of Veterans Affairs and federal civil service pensions fell
below the program's income eligibility ceiling.
The letters provided information in English or Spanish about the Medicare
savings programs, including state-specific asset guidelines and a state
contact number.19 (See app. II for a sample 2002 outreach letter.) At the
end of November 2002, SSA sent a separate mailing to about 53,000 disabled
working adults who were potentially eligible for benefits under the QDWI
program.20
Medicare beneficiaries who had sources of income other than Social
Security-such as income from employment and public and private
pensions-and whose incomes were above the programs' eligibility thresholds
were selected nonetheless to be sent the SSA outreach letter because SSA's
data systems do not collect information on these income
17SSA officials stated that the mailings were based on the last two digits
of the recipients' Social Security numbers, which are random and not based
on any geographic, age, or other demographic characteristic. For each
mailing, SSA's mail vendor selected approximately 207,000 letters based on
this sequence, and then sorted the letters by zip code before mailing them
out.
18SSA elected to send this mailing only to individuals potentially
eligible for the QMB, SLMB, and QI-1 programs. SSA did not have current
income data needed to select potentially eligible QDWI individuals. The
FPL for an individual in the 48 contiguous states was $8,860 in 2002. For
a couple, the FPL was $11,940. The FPL is higher in Alaska and Hawaii.
19Letters were sent in either English or Spanish based on the language
preference provided to SSA in the past.
20The QDWI letters were timed by SSA to arrive near the general enrollment
period for Medicare part A, which runs from January 1 through March 31
each year.
sources. In addition, SSA's records do not contain information about
beneficiaries' private assets, making it impossible for SSA to identify
whether letter recipients had assets within their states' Medicare savings
programs' eligibility limits-typically $4,000 for an individual and $6,000
for couples.
In 2002, the Medicare Rights Center, a national health advocacy group for
older adults and people with disabilities, sought a federal court order
requiring SSA to resend 1.4 million letters to potentially eligible
beneficiaries in Connecticut and New York to correct erroneous information
on the asset limit for the QI program. The New York and Connecticut
letters had incorrectly informed potential beneficiaries that only
individuals with assets of less than $4,000 were eligible for the QI
program, even though Connecticut and New York abolished the asset
requirement for QI eligibility in 2001 and 2002, respectively. SSA agreed
to resend the letters and the parties settled the case before trial.
In addition to sending letters to potentially eligible low-income Medicare
beneficiaries, in 2002 SSA provided all but six states with an electronic
data file containing the names of all beneficiaries to whom it had sent
letters in that state.21 The data file contained information that could
assist states with outreach efforts, such as the name, address, Social
Security number, date of birth, spouse's name, and the basis for Medicare
entitlement of each letter recipient. SSA is required to provide updated
data to the states each year.22
For the June through October 2003 mailing, SSA sent a second round of
letters to about 4.3 million potentially eligible low-income Medicare
beneficiaries nationwide whom its records indicated might have met the
QMB, SLMB, and QI income eligibility criteria and were not currently
enrolled in Medicare savings programs. This mailing included beneficiaries
who were newly eligible since the 2002 mailing, current Medicare
beneficiaries who newly met the income criteria,23 and about one-fifth of
the beneficiaries notified in 2002 who still met the mailing criteria but
21SSA's security protocol requires states to provide certain information
in order for SSA to send the data files. Six states did not provide this
information and therefore SSA did not send the data file to them.
2242 U.S.C. S: 1320b-14(b)(1)(B) (2000).
23For example, individuals who did not previously receive an outreach
letter may subsequently meet the income criteria due to reduced income
from the death of a spouse.
were not enrolled in a Medicare savings program.24 At the time we
conducted our work, enrollment data for beneficiaries who were sent the
letter in 2003 were not available.
In contrast to the 2002 letter that provided state-specific eligibility
criteria and a state-specific telephone number, the 2003 letter did not
contain customized state information, but provided more general national
information. The letter suggested that beneficiaries who may be eligible
check the government list in their local telephone books for their local
Medicaid contact or call the general 1-800-Medicare number that refers
callers to state help lines, such as state or local medical assistance
offices, social services, or welfare offices. SSA gave several reasons for
not including state-specific information in the 2003 letter. One official
indicated that there was additional cost to SSA to develop state-specific
letters and therefore the agency did not tailor the letters for each
state. CMS officials reported that a few states did not want to provide
state-level contact numbers because eligibility and other Medicare savings
program administrative matters were actually conducted at the county
levels. Furthermore, in some cases, the telephone numbers states initially
provided were changed shortly before the 2002 mailings were begun,
creating additional need for SSA to coordinate with states in finalizing
the letters. However, some state officials we interviewed expressed
concern about the lack of state-specific information for the 2003 mailing.
Their concern was that, given that most states had established mechanisms
for responding to these inquiries for the larger 2002 mailing, not
including state-specific criteria or contact information on the letter
could make the letter less effective since it could be more difficult for
beneficiaries to obtain direct assistance or applications for eligibility
determinations.
24Thus, over a period of 5 years, SSA will resend letters to all 2002
letter recipients who still meet the mailing criteria but have not
enrolled in Medicare savings programs.
Medicare Savings Program Enrollment Increased by More than 74,000
Beneficiaries Following the 2002 SSA Mailing
We estimate that SSA's mailing from May through November 2002 to 16.4
million potentially eligible beneficiaries contributed to more than 74,000
additional beneficiaries enrolling in Medicare savings programs. Further,
in the year following SSA's mailing, nationwide enrollment in Medicare
savings programs increased 2.4 to 2.9 percentage points over that in the 3
previous years. Certain demographic groups also had larger additional
increases in enrollment following the 2002 SSA mailing. For example,
beneficiaries less than 65 years old, persons with disabilities,25 racial
and ethnic minorities, and residents in southern states experienced larger
additional increases in enrollment.
More than 74,000 Additional Beneficiaries Enrolled in Medicare Savings
Programs Following SSA's 2002 Mailing
On the basis of our analysis of SSA's Master Beneficiary Record (MBR), we
estimate that, of the 16.4 million SSA letter recipients in 2002, an
additional 74,000 beneficiaries (0.5 percent of letter recipients)
enrolled in Medicare savings programs than would have likely enrolled
without the mailing. To estimate this increased enrollment, we examined
two cohorts of letter recipients-a cohort of 1.3 million beneficiaries who
were sent the letters during the first six mailings in May 2002 and a
baseline cohort of 1.3 million beneficiaries who were sent the letters
during the last six mailings through November 2002. Because SSA sent the
mailing to beneficiaries in a random order nationwide from May through
November 2002, the only difference between the cohorts is the time at
which the letters were sent to them. As a result, other factors that could
influence enrollment patterns, such as demographic differences or other
outreach efforts by CMS and the states, should affect the May and November
cohorts similarly. We used the November 2002 cohort as a baseline to
examine how the May 2002 cohort's enrollment in Medicare savings programs
was affected following SSA's mailing.
As shown in figure 1, by August 2002-3 months after the initial letters
were sent in May 2002-the Medicare savings program enrollment for the May
cohort began to increase faster than that of the November cohort, which
was yet to have the SSA letter sent to them. While the cohorts were sent
the SSA letters in May or November 2002, SSA officials reported that it
typically takes about 3 months before enrollment is reported in the MBR.
25Persons with disabilities are persons of any age who are unable to do
any kind of substantial gainful activity because of a physical or mental
impairment (or a combination of impairments) that has lasted or is
expected to last for a continuous period of at least 12 months, or that is
expected to result in death. 42 U.S.C. S: 416(i)(1)(A) (2000).
Figure 1: Medicare Savings Programs Enrollment in Two Sample Cohorts of
SSA Letter Recipients, June 2002 through December 2002
aThe baseline is the cohort that was sent the letter in November 2002.
As of December 2002, more than 5,800 additional beneficiaries in the
cohort of 1.3 million beneficiaries who were sent the letter in May had
enrolled in Medicare savings programs compared with the November cohort,
whose enrollment was not yet affected by the mailing.26 (See table 3.)
This additional enrollment in the May cohort represents 0.5 percent of the
letter recipients. Projecting the experience of the May cohort to the
universe of the 16.4 million letter recipients results in an estimate of
over 74,000 additional beneficiaries enrolling in Medicare savings
programs as a result of the 2002 SSA mailing.
26After December 2002, additional enrollment among the baseline group
began increasing faster than the May cohort, indicating that the maximum
cumulative effect of the 2002 SSA mailing for the May cohort relative to
the baseline occurred as of December 2002.
Table 3: Enrollment in Medicare Savings Programs by Sample Cohort,
December 2002
Cohort that the
SSA letter was Baseline
sent
to in May 2002 cohorta Difference
Number of letter recipients in
sample
cohort who enrolled 30,291 24,473 5,818
Percent of letter recipients
who
enrolled 2.4 1.9 0.5
Estimated total number of
recipients
who enrolled 386,243 311,786 74,457
Source: GAO analysis of SSA MBR data.
Note: Each cohort included 1.3 million letter recipients.
aThe baseline represents the cohort that was sent the letter in November
2002 because the effect of the letter was not yet evident during the
period we analyzed.
Nationwide, CMS data showed that Medicare savings programs experienced an
overall net increase in enrollment of 5.9 percent (341,069 individuals)
from May 2002-the start of SSA's mailing-to May 2003.27 This 5.9 percent
increase was nearly double the 3.0 to 3.5 percent increases in the 3
previous years before SSA's nationwide mailings. (See table 4.) These data
suggest that SSA's mailing helped to increase enrollment at a greater
annual rate than in earlier years.
27The CMS data showing about a 341,000 increase in Medicare savings
program enrollment from May 2002 to May 2003 represents the net change in
enrollment including both increases (due to new enrollees) as well as
decreases (due to former program enrollees who died or otherwise were no
longer enrolled). Our analysis of the SSA MBR data, estimating an increase
in enrollment following the SSA mailing of about 386,000 beneficiaries,
reflects only new enrollees because the SSA letter went only to those
beneficiaries not enrolled in Medicare savings programs at the time.
Table 4: Medicare Savings Program Enrollment, May 1999 to May 2003
Annual change in Annual percentage
Month/year Enrollment enrollment Increase
May 1999 5,242,378 - -
May 2000 5,398,468 156,090
May 2001 5,570,231 171,763
May 2002 5,763,553 193,322
May 2003 6,104,622 341,069
Source: GAO analysis of CMS third-party master file.
Certain States and Demographic Groups Had Higher Enrollment Rates Following
SSA's Outreach
Across the United States, letter recipients residing in the southern
states had a 0.6 percent additional increase in enrollment following SSA's
mailing. This was more than residents in the Northeast, Midwest, and West,
where the additional increase in enrollment was 0.4 percent. Thirtyfive
states had an additional increase in enrollment following the SSA mailing
compared to the increase that would likely have occurred without the
letter. Of the thirty-five states, the largest additional increase in
enrollment following the SSA mailing occurred in Alabama, (2.9 percent),
followed by Delaware (2.0 percent), and Mississippi (1.3 percent). While
data from 13 other states showed an increase in enrollment following the
SSA mailing, these increases were not statistically significant. Another
three states showed a decrease in enrollment following the SSA mailing,
but these changes also were not statistically significant. Appendix III
provides the additional percentage change in enrollment following the 2002
SSA mailing for each state.
Certain demographic groups also had higher additional increases in
enrollment rates than the additional increase among all letter recipients.
In comparison to the 0.5 percent additional increase in enrollment among
all letter recipients, beneficiaries less than 65 years old and
beneficiaries of any age who qualified for Medicare as a result of a
disability each had a 0.8 percent additional increase in enrollment
following SSA's outreach.28 Also, minority beneficiaries, which based on
SSA's data categories include blacks or individuals of African origin,
Asians and Pacific Islanders, and North American Indians or Eskimos, had a
0.7 percent additional increase
28We calculated age as of May 10, 2002, the first date of the SSA mailing,
using the beneficiary's date of birth.
Enrollment Increases Varied among Selected States We Reviewed, with Several
Reporting Increased Calls and Applications Concurrent with SSA Mailing
in enrollment. Appendix IV provides data for all demographic groups that
we examined.
The percentage of additional letter recipients newly enrolling in Medicare
savings programs following SSA's mailings varied significantly among the
six states we reviewed. Among these six states, enrollment increases
ranged from 0.3 to 2.9 percent. Further, several states we reviewed
reported that calls to their telephone hot lines and applications mailed
or received increased sharply during the period of the SSA outreach. In
addition, some states supplemented SSA efforts with outreach efforts of
their own, while other states were aware of or assisted outreach efforts
by private or community groups.
SSA Outreach Efforts Had Varying Effects on Enrollment in Selected States
Among the states we reviewed, SSA's outreach had varying effects on the
percentage of letter recipients enrolling. Alabama, with 2.9 percent
additional letter recipients enrolled compared to the percentage that
likely would have enrolled without the SSA letter, had the largest
additional increase in enrollment following the SSA mailing. This
contrasts with the national average of 0.5 percent. For the states we
reviewed, SSA's outreach had the least impact on Medicare savings program
enrollment in California, Washington, and New York with a 0.3 percent
increase in additional enrollment. (See table 5.)
Table 5: Increase in Enrollment following SSA's Outreach to Targeted
Population in Six Selected States, December 2002
Percentage of additional letter recipients State enrolling following SSA
mailing
Alabama 2.9
Louisiana 0.9
Pennsylvania 0.4
California 0.3
Washington 0.3
New York 0.3
All States 0.5
Source: GAO analysis of SSA's Master Beneficiary Record.
The varying effects on enrollment by state can be attributed to several
factors, including, the share of eligible beneficiaries already enrolled
in Medicare savings programs prior to the outreach, a state's ability to
handle increased phone calls and applications, and a state's income and
asset limits. For example, a smaller share of low-income elderly
beneficiaries in Alabama was enrolled in QMB as of the year prior to the
SSA mailing than the national average. Specifically, the number of QMB
enrollees in Alabama in 2001 was about half the number of Alabama seniors
reported by the Census Bureau to have incomes below the limit for the QMB
program. In contrast, about three-quarters of the seniors nationwide who
reported income below the QMB limit were enrolled. As a result, a larger
number of letter recipients in Alabama may have been able to meet the QMB
and other Medicare savings program eligibility criteria whereas other
states may have already enrolled a larger share of these beneficiaries.
Further, each of the states we reviewed established or used an existing
state-specific telephone number that was listed in the SSA letter to
receive calls. After the SSA mailing started, however, California's phone
number was discontinued and calls were redirected to CMS's nationwide
1-800-Medicare number. California's lower enrollment could also result
from its eligibility requirements for SSI. For example, in a prior
demonstration, SSA's mailing in 1999 and 2000 resulted in lower enrollment
in California than in other demonstration sites, in part because the state
offered a generous state supplement to SSI. Therefore, there were
potentially not as many people eligible for the Medicare savings
programs.29 In addition, other state differences, such as different state
asset eligibility requirements and application requirements as well as
state efforts to support the SSA outreach, may have contributed to
different effects among states.
States Reported Increased Interest in Medicare Savings Programs Concurrent
with SSA and States' Outreach Efforts
States we reviewed often reported that calls to their hot lines and
applications for Medicare savings programs increased significantly during
the period of the 2002 SSA mailing. Four states provided data on the
monthly trends in the number of calls either related to Medicare and
Medicaid in general or the Medicare savings program specifically that
showed increases concurrent with the 2002 SSA mailing. Three states were
also able to provide data on changes in the number of applications sent to
interested beneficiaries or received from beneficiaries. (See table 6.)
While
29See Lisa Maria B. Alecxih et al, Results from the SSA Buy-In
Demonstration: Final Report.
officials in several states indicated that not all of the increases noted
could be attributed directly to the SSA mailing, the data provided by the
states suggest that beneficiaries' interest in Medicare savings programs
increased during the mailing period. For example, Alabama experienced a 19
percent increase in monthly calls to its state hot line related to any
Medicare and Medicaid issue after the SSA mailings began; this was
followed by a 25 percent decrease after the mailings ended. Alabama also
experienced a 158 percent surge in applications received per month during
the SSA mailing and then a decrease of 57 percent afterwards. State
officials reported that Washington tracked calls and applications specific
to the SSA mailing, and these data showed 85 percent decreases in both
monthly call volume and applications mailed out to beneficiaries after the
mailings ended; Washington also reported a 72 percent monthly decrease in
applications received after the 2002 mailings ended.
Table 6: Average Monthly Calls and Applications Related to Medicare
Savings Programs for Four States prior to, during, and/or after SSA's
Mailing Outreach, January 2002 to April 2003
State Average monthly calls
Average monthly applications
Alabama Average monthly calls for any Medicaid or Medicare issue
(including Medicare savings programs):
o Prior to: 25,133
o During: 30,010 (19 percent increase)
o After: 22,485 (25 percent decrease) Average monthly applications
received related to Medicare (including Medicare savings programs):
o Prior to: 1,474
o During: 3,802 (158 percent increase)
o After: 1,618 (57 percent decrease)
Louisiana Average monthly calls for Medicare savings programs:
o Prior to: 301
o During: 1,849 (515 percent increase)
o After: 516 (72 percent decrease) Average monthly applications mailed
for Medicare savings programs:a
o Prior to: 53
o During: 1,571 (2,865 percent increase)
o After: 226 (86 percent decrease)
Average monthly applications received for Medicare savings programs:
o Prior to: 2,131b
o During: 2,940 (38 percent increase)
o After: 3,634 (24 percent increase
Pennsylvania Average monthly calls for Medicare savings programs:
o Prior to: 1,095
o During: 4,418 (303 percent increase)
o After: 2,039 (54 percent decrease)
Washington Average monthly calls for Medicare savings programs specific
to the SSA mailing:
o Prior to: not available
o During: 1,180
o After: 175 (85 percent decrease)
c
Not available
Average monthly applications mailed to beneficiaries in response to the
SSA mailing:
o Prior to: not available
o During: 1,127
o After: 168 (85 percent decrease)
State Average monthly calls
Average monthly applications
Washington Average monthly applications
(continued) received in response to the SSA mailing:
o Prior to: not available
o During: 436d
o After: 121 (72 percent decrease)
Source: GAO analysis of data from selected states.
Note: Unless otherwise noted, the period prior to the SSA mailing included
January through April 2002; the period during the mailing was May through
November 2002; and the period after the mailing was December 2002 through
April 2003.
aLouisiana provided data on the number of applications that were sent to
beneficiaries from the state's Medicaid office. These averages do not
include applications mailed by other agencies or organizations across the
state, which may explain why more applications were received than mailed
during the same period.
bWe did not include January 2002 applications in the monthly average
because of a large surge in applications during that month, which was
probably attributable to the state's QI program temporarily closing and
reopening for enrollment.
cPennsylvania reported that about 0.5 percent of individuals sent the SSA
mailing filed applications, and 73 percent of filed applications were
approved, but the officials could not provide monthly data.
dData on applications received were not available for May and June 2002
and are not included in the average.
Concurrent with SSA's mailing, each of the states we reviewed reported
that the state or other stakeholders conducted additional outreach. For
example, the Louisiana Department of Health and Hospitals and the
Pennsylvania Health Law Project, a coalition advocating for low-income
individuals and the disabled, each received 3-year grants from the Robert
Wood Johnson Foundation in 2002 to conduct outreach to low-income Medicare
beneficiaries in these states. A state official also reported that in 2002
the New York Department of Health developed and distributed 100,000 copies
of a brochure called "How To Protect Your Health and Money," which
included information about the Medicare savings programs, and conducted a
"Senior Day" at 16 sites in New York City and several other districts as
well as presentations at local fairs. Other states reported coordinating
with community or state organizations as well as private health plans
participating in Medicare, such as health maintenance organizations
participating in the Medicare + Choice program.30 Some private health
plans conducted outreach to increase Medicare savings program enrollment
since CMS pays these plans a higher rate for these
30California officials also reported that Medicare health maintenance
organizations in California provided outreach through private contractors
approved by CMS.
Agency and State Comments
enrollees. Several state officials also said that their states work with
other groups, such as the local departments of aging or senior services
and local businesses and community organizations, to assist with outreach
efforts to potentially eligible beneficiaries. None of the states we
reviewed reported having assessed the effectiveness of their outreach
efforts.
Of the six states we reviewed, only Louisiana and Pennsylvania officials
reported that they used the data file listing names and addresses of
potentially eligible beneficiaries provided by SSA in 2002 to assist with
state outreach or enrollment efforts. For example, after receiving the SSA
data file, seven parishes in Louisiana used it to obtain a list of
potentially eligible beneficiaries and sent an application with a letter
and return envelope to these beneficiaries. In 2003, about 20,450
applications were mailed to potential beneficiaries. Pennsylvania
officials used the file to cross-check against the state's own data system
to assess the number of applications authorized, rejected, or denied as a
result of the SSA mailing.
We provided a draft of this report to SSA, CMS, and state Medicaid
agencies in Alabama, California, Louisiana, New York, Pennsylvania, and
Washington. In written comments, SSA generally concurred with our findings
and provided technical comments that we incorporated as appropriate. SSA
also noted that improvements in state enrollment processes could further
increase enrollment. SSA's comments are reprinted in appendix V. In a
written response, CMS stated it did not have any specific comments on the
report. However, CMS provided technical comments that we incorporated as
appropriate.
While we did not examine the effects of SSA's 2003 mailing, Louisiana
Medicaid officials indicated that, in comparison to the 2002 SSA mailing,
there was little increase in call volume following SSA's 2003 mailing, and
that they believe that this was because a state-specific telephone number
was not included in the 2003 outreach letter. New York Medicaid officials
stated that they found an increase in Medicare savings program enrollment
of over 6 percent from December 2002 to December 2003. However, in
addition to being a different timeframe from what we examined, we do not
believe that all of this increase can be attributed to the SSA mailing.
Based on our analysis of SSA's MBR data, we report a 0.3 percent increase
in enrollment in New York specifically attributable to the 2002 SSA
outreach mailing. We found the net increase in enrollment from May 2002 to
May 2003 (following SSA's 2002 mailing) to be 5.9 percent nationwide,
similar to the net increase in enrollment that New York reported from
December 2002 to December 2003. Louisiana and Pennsylvania Medicaid
officials
also provided technical comments that we incorporated as appropriate.
Alabama, California, and Washington Medicaid officials reviewed the draft
and stated that the report accurately reflected information relevant to
their respective states.
We are sending copies of this report to the Commissioner of SSA, the
Administrator of CMS, and other interested parties. We will also provide
copies to others on request. In addition, this report will be available at
no charge on GAO's Web site at http://www.gao.gov.
Please call me at (202) 512-7118 or John Dicken at (202) 512-7043 if you
have any additional questions. N. Rotimi Adebonojo and Rashmi Agarwal were
major contributors to this report.
Kathryn G. Allen Director, Health Care-Medicaid and Private Health
Insurance Issues
List of Committees
The Honorable Charles E. Grassley
Chairman
The Honorable Max Baucus
Ranking Minority Member
Committee on Finance
United States Senate
The Honorable Joe Barton
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives
The Honorable William M. Thomas
Chairman
The Honorable Charles B. Rangel
Ranking Minority Member
Committee on Ways and Means
House of Representatives
Appendix I: Methodology
To determine what outreach the Social Security Administration (SSA)
conducted in response to the statutory requirement, we obtained and
reviewed copies of SSA documents, including sample 2002 and 2003 outreach
letters and data on the number of letters sent to eligible Medicare
beneficiaries in each state, as well as reports prepared by the Centers
for Medicare & Medicaid Services (CMS) related to the Medicare savings
program. In addition, we interviewed officials from the SSA and CMS.
To determine how enrollment changed following SSA's outreach, we analyzed
records from SSA's Master Beneficiary Record (MBR)1-a database that
contains the administrative records of Social Security beneficiaries,
including payments for Medicare premiums-and CMS's national enrollment
data for the Medicare savings programs. The MBR data contain demographic
information as well as information on the monthly deductions made from
beneficiaries' Social Security checks to cover Medicare part B premiums.2
We obtained MBR data on beneficiaries who were sent the outreach letters
in the first six mailings in May and the last six mailings through
November 2002,3 representing 2.6 million of the 16.4 million Social
Security beneficiaries who were sent letters from SSA. To determine which
letter recipients enrolled in the Medicare savings programs following
SSA's 2002 mailing, we identified letter recipients who met the following
criteria:
o those whose date of eligibility for Medicare savings programs began
January 2002 or afterwards;
o those for whom a third-party payer, specifically a state, made
payments on their behalf to cover Medicare part B premiums; 4 and
1The MBR contains records for Social Security beneficiaries who were
entitled to receive benefits under the Old-Age, Survivors and Disability
Insurance program. SSA provided us with certain records from the MBR that
included demographic information as well as Medicare benefit payments.
2For Medicare beneficiaries who elect to participate in Medicare part B,
SSA typically withholds an amount equal to their Medicare part B premium
from their monthly Social Security checks.
3Mailing dates for the May cohort include those from May 10 through May
22, 2002, and for the November cohort include mailing dates from October
28 through November 8, 2002.
4MBR data show third-party payments from three sources-a state, a private
payer, or federal civil service.
Appendix I: Methodology
o those who no longer had the premium deduction made from their Social
Security checks to cover Medicare part B premiums at any point from June
2002 through December 2002.5
In order to estimate the impact of the SSA outreach mailing on additional
enrollment in Medicare savings programs, we analyzed monthly enrollment
from June 2002 to December 2002 for two cohorts of letter recipients to
identify letter recipients who enrolled in Medicare savings programs
following the initiation of the SSA mailing in May 2002.6 Because the
mailings were sent to beneficiaries in a random order, the only notable
difference between the recipients in the two cohorts would be the timing
of when the SSA letters were sent to them. SSA officials noted that it
typically takes about 3 months until enrollment is reported on the MBR.
Therefore, since the mailings began in May 2002, the first effects of the
mailing would not have been apparent until after June 2002. We analyzed
the MBR data provided by SSA to determine specifically what month and year
a letter recipient enrolled in Medicare savings programs. Using the
enrollment by the November cohort as a baseline because these individuals
met the same selection criteria as those in the May cohort, we estimated
the net effect of the SSA mailing by comparing the difference in
cumulative monthly enrollment between the May and November cohorts in
December 2002-this difference represented the additional enrollment we
attributed to the SSA mailing.7 We made the comparison in December 2002
because after this date the enrollment of the baseline group began
increasing at a rate faster than the May cohort, indicating that this was
the point when the largest cumulative difference in enrollment between the
two cohorts occurred before the effects of the mailing started becoming
evident for the November cohort. Using the same methodology, we calculated
the effect of the SSA outreach letter for certain demographic
5When a Medicare beneficiary enrolls in a Medicare savings program, the
Medicare part B premium is no longer deducted from the beneficiary's
Social Security check but is instead paid by the state.
6Our data for both cohorts did not include beneficiaries potentially
eligible for QI-2 or the 53,000 beneficiaries who were sent a November
2002 SSA mailing about potential eligibility for the separate QDWI
program.
7Our analysis may not include potential beneficiaries in the May cohort
who significantly delayed presenting a Medicare savings program
application to state Medicaid offices for eligibility screening or those
whose applications were in the eligibility determination process after
December 2002. In addition, some letter recipients in the November cohort
may have enrolled prior to receiving the letter because they learned about
the programs from others, such as neighbors or relatives, who already
received the mailing.
Appendix I: Methodology
groups and for beneficiaries in each state. We also obtained and analyzed
data contained in CMS's third party master file for the period May 1999 to
May 2003 that tracks national Medicare savings programs enrollment.8 Using
these data, we examined how national Medicare savings enrollment trends
compared before and after the 2002 SSA mailing.
To determine how additional enrollment in the programs changed in selected
states following SSA's outreach and what outreach efforts these states
undertook, we interviewed Medicaid officials in six states- Alabama,
California, Louisiana, New York, Pennsylvania, and Washington. We selected
these states based on several factors, including states with different
levels of change in overall Medicare savings programs enrollment from 2002
to 2003, geographic diversity, relatively large populations of Medicare
savings programs enrollees, and availability of data on program
enrollment. We also reviewed CMS's third party master file to identify how
many beneficiaries in each state were enrolled in Medicare savings
programs, and analyzed records from SSA's MBR to estimate the additional
enrollment in each state following the SSA mailing. In addition, we
obtained information from each state to the extent available on its
involvement with the SSA mailing, the state's specific eligibility
criteria for its Medicare savings program, outreach efforts conducted by
the state to low-income Medicare beneficiaries, and state data on call and
application volume before, during, and after the SSA outreach.
We obtained information from SSA and CMS on their data reliability checks
and any known limitations on the data they provided us. SSA and CMS
perform quality controls, such as data system edits, on the MBR and the
third party beneficiary master file, respectively. We concluded that their
data were sufficiently reliable for our analysis. A few MBR variables have
certain limitations. For example, some Medicare beneficiaries receive
their Social Security payments electronically, and therefore may not keep
the record of their mailing address current. For our analysis we only used
the beneficiary's state of residence, which is less likely to change as
SSA reported that, even if a beneficiary's address changes, the
beneficiary often
8The third-party master file contains records for Medicare beneficiaries
for whom a third party, such as a state welfare agency or a private group
payer, pays their Medicare part A or B premiums. SSA's field offices,
state welfare agencies, private groups, and the Office of Personnel
Management collect the information and send it to CMS for monthly updates.
CMS uses these data to track enrollment and bill states and other groups
accordingly.
Appendix I: Methodology
stays within the same state of residence. Finally, since it is optional
for beneficiaries to identify their race, a number of Social Security
recipients do not. However, sufficient numbers of individuals reported
their race to to allow us to analyze these data and also report missing or
unknown values.
Appendix II: SSA 2002 Outreach Letter
SSA mailed 16.4 million letters in 2002 to potentially eligible Medicare
beneficiaries notifying them about state Medicare savings programs. These
letters were customized to include state-specific information, including a
state contact number. These letters were sent in English or Spanish,
depending on the beneficiary's preference. Figure 2 provides a sample of
the outreach letter sent to a beneficiary in Texas between May and
November 2002.
Appendix II: SSA 2002 Outreach Letter
Figure 2: Sample 2002 SSA Letter
Source: SSA.
Appendix III: Medicare Savings Program Enrollment following 2002 SSA Mailing by
State
Figure 3 shows enrollment by state of the estimated 74,000 additional
beneficiaries who enrolled in Medicare savings programs following the 2002
SSA mailing. Because these estimates are based on two cohorts of about 1.3
million beneficiaries each that represent a sample of the entire
population of 16.4 million beneficiaries, we calculated 95 percent
confidence intervals to reflect the potential for statistical error in
projecting these estimates from the sample cohorts to the entire
population. The small sample size in states with smaller populations
results in larger confidence intervals for the estimates for these states.
The highest additional increase in enrollment was in Alabama, in which an
estimated 2.9 percent (with a 95 percent confidence interval of 2.6
percent to 3.3 percent) of beneficiaries who were sent the SSA letter
enrolled than if the mailing had not occurred. In three states (Montana,
Utah, and Vermont) our analysis showed no additional or slightly negative
enrollment following the SSA mailing, and because the confidence intervals
for these and 13 other states overlap the numeric value zero, the data do
not show a statistically significant change in additional enrollment in
the Medicare savings programs following the 2002 SSA mailing for these
states. The other 35 states showed a statistically significant increase in
additional enrollment in the Medicare savings programs following the 2002
SSA mailing.
Appendix III: Medicare Savings Program Enrollment following 2002 SSA
Mailing by State
Figure 3: Estimated Percentage Change in Medicare Savings Program
Enrollment Following 2002 SSA Mailing by State, December 2002
Appendix IV: Medicare Savings Program Enrollment following 2002 SSA Mailing by
Demographic Group
On the basis of our analysis of SSA's MBR, we estimate that enrollment in
Medicare savings programs was about 74,000 higher for Medicare
beneficiaries following the 2002 SSA mailing than it would have been
without the mailing. This represents about 0.5 percent of the 16.4 million
letters sent nationwide. However, this additional enrollment following the
SSA mailing varied among demographic groups.
Figure 4 shows the additional enrollment in Medicare savings programs
following the 2002 SSA mailing by geographic region and demographic
groups, including racial categories, sex, disability status, and age
categories. Because these estimates are based on two cohorts of about 1.3
million beneficiaries each that represent a sample of the entire
population of 16.4 million beneficiaries, we calculated 95 percent
confidence intervals to reflect the potential for statistical error in
projecting these estimates from the sample cohorts to the entire
population. Additional enrollment following the 2002 SSA mailing was
statistically significantly higher among beneficiaries in southern states
compared to other geographic regions, minorities compared to white
beneficiaries, beneficiaries with disabilities compared to beneficiaries
without disabilities, and beneficiaries who were younger than 65 years
compared to those who were 65 years or older.
Appendix IV: Medicare Savings Program Enrollment following 2002 SSA
Mailing by Demographic Group
Figure 4: Estimated Percentage Change in Medicare Savings Program
Enrollment Following 2002 SSA Mailing by Demographic Group, December 2002
Note: Some estimates do not show an upper or lower bound because the 95
percent confidence interval was the same as the point estimate due to
rounding.
aBased on SSA's data categories, "minority" includes blacks or individuals
of African origin, Asians and Pacific Islanders, and North American
Indians or Eskimos.
Page 38 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries
Appendix V: Comments from the Social Security Administration
Related GAO Products
Medicare and Medicaid: Implementing State Demonstrations for Dual
Eligibles Has Proven Challenging. GAO/HEHS-00-94. Washington, D.C.: August
18, 2000.
Low-Income Medicare Beneficiaries: Further Outreach and Administrative
Simplification Could Increase Enrollment. GAO/HEHS99-61. Washington, D.C.:
April 9, 1999.
Medicare and Medicaid: Meeting Needs of Dual Eligibles Raises Difficult
Cost and Care Issues. GAO/T-HEHS-97-119. Washington, D.C.: April 29, 1997.
Medicare and Medicaid: Many Eligible People Not Enrolled in Qualified
Medicare Beneficiary Program. GAO/HEHS-94-52. Washington, D.C.: January
20, 1994.
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