Enrolling Dual Eligibles: Current Process and Barriers

1. Current Process for Enrolling Dual Eligibles Kenneth D. Nibali, Consultant on Social Security Former Associate Commissioner for Disability with the Social Security Administration

2. Medicare Enrollment •Conducted by the Social Security Administration •Social Security application (age or disability) also application for Medicare •Social Security retirement benefits can begin as early as age 62, and disability benefits can begin at much earlier ages •Medicare benefits do not begin until –a person is age 65, or –a person has been disabled for 24 months •Delay for many people between applying for Social Security and receiving Medicare –about 75% of retirees apply before age 65 –disabled persons have a 24 month waiting period •CMS sends initial enrollment package to individuals 3 months before they become Medicare eligible

3. Medicaid Enrollment •Conducted by the states according to state rules •Individuals must provide information about income and assets •Application through state offices, often welfare offices •State computer-based systems help determine which programs people qualify for, Medicaid or other medical assistance programs •States must periodically re-examine income and assets to determine continuing eligibility

4. Medicaid Enrollment at SSA •Medicaid enrollment may result from applying for SSI benefits at Social Security offices •Social Security claimants approaching age 65 or claiming disability are screened for SSI eligibility •SSI carries Medicaid eligibility, but states may have different rules –32 states and DC have SSA make Medicaid decision under SSI rules –7 states and Northern Marianna Islands use SSI rules but require separate application with the state –11 states require separate application and use more restrictive rules than the SSI rules •In the 7 and 11 States: –SSA refers people to States to file Medicaid applications and provides information to the States –SSA estimates that 10-20% do not follow through

5. Enrolling Duals: Program Interactions •Contacting State first for medical assistance –Screen for MSP eligibility –Verify that they are receiving Medicare if eligible •Contacting SSA and found eligible for SSI –Where SSA makes the Medicaid decision, eligibility triggers MSP coverage 32 states –Where separate Medicaid application is required, other 18 States must make decision •For low-income disabled beneficiaries waiting 24 months for Medicare, states usually provide interim assistance

6. Barriers to Enrollment •Lack of beneficiary awareness •Beneficiary limitations •Lack of knowledge by some intake workers •State Medicaid office setting •Difficulty with application •Asset reporting •Inadequate systems integration

7. Efforts to Increase Enrollment- States •GPRA goal •New State activity –Printed materials –Direct mail –Presentations at community sites –Special training for intake workers –Partnerships with Federal/State agencies •Simplified application

8. Efforts to Increase Enrollment- SSA •Despite limits in funding, SSA conducts outreach efforts –Information in publications, handouts, and fact sheets –Advertisement in check-stuffers and COLA notices –Instructions in SSA field office manuals –Information on SSA toll-free telephone lines •BIPA requires SSA to annually identify potential MSP eligibles, contact them, and provide list to states –16.5 million mailings in 2002 –4.25 million (additional) in 2003 –24 million in each of 2004 and 2005 (includes nformation on drug discount card) –About 6 million in 2006 and beyond •GAO estimates that –75,000 additional MSP enrollees because of letters –Enrollment in year after mailings was double any of previous 3 years

9. Efforts to Increase Enrollment- SSA Outreach Pilots •In 1999, SSA tested federal/state partnerships to evaluate ways to increase MSP participation •Tested 8 different models to address lack of knowledge of program, the welfare office stigma, and resistance to filing •1.5 million letters sent to Medicare beneficiaries in 16 states who were told to call for different processes –screened by SSA and referred to state for processing –screened by SSA and referred to state employee in SSA office –screened by SSA, application taken by SSA, forwarded to state for processing –told to contact an AARP representative to help them make application –screened by SSA, application taken by SSA, and decision made by SSA

10. Efforts to Increase Enrollment- SSA Outreach Pilots (cont.) •Overall the efforts increased MSP enrollments about 7%, but some models increased 10% •Generally greater participation and buy-in to the MSP as the amount of SSA involvement increased

11. Implications of Current Processes •Current processes work better when: –SSA enrolls individuals in Medicare –States use SSA’s eligibility determination for SSI –Individuals apply for State medical assistance –Individuals are served by medical institutions who want reimbursement

12. Implications of Current Processes •Current processes work less well when: –SSA refers individuals to States for application –Individuals have not filed for State assistance –Individuals have special needs because of illness, age, language –Individuals are concerned about asset and estate recovery rules –Individuals don’t have someone they trust to explain complex program rules or applications

13. The Future- Possible Prescription Drug Plan Tie-ins • First priority is to bring up the PDP processes so that a stable base exists • Possible Tie-ins with MSP and PDP Subsidy population • Use of I&R data on PDP subsidy applicants to refine 1144 mailings by SSA • Sharing of PDP subsidy applicants I&R data with the States for MSP eligibility followups (privacy issues to be addressed) • Use of PDP subsidy applicants I&R data by SSA or other parties to determine MSP eligibility for States (privacy issues)