Stark reintroduces legislation to help enroll dual-eligibles in Medicaid cost-sharing benefit

Advocates are frustrated by very low’ participation

Two new studies indicate Medicaid programs to help the low-income elderly meet the cost-sharing requirements of Medicare are falling short of the mark, prompting reintroduction of federal legislation that would automatically enroll dual-eligibles.

"It’s hard to bring attention to this population because it’s not particularly vocal," says JoAnn Lamphere, DrPH, a senior policy advisor with the Public Policy Institute of the American Association of Retired Persons in Washington, DC. "These are older people; most of them are women. They’re just kind of quiet about things."

Jump-starting enrollment

Rep. Pete Stark (D-CA), who requested a General Accounting Office (GAO) report on the programs known colloquially as "quimby" and "slimby," has responded to the findings by reintroducing, with Rep. Jim McDermott (D-WA), a proposal to allow the Social Security Administration (SSA) to jump-start the enrollment process for eligible beneficiaries. Based on income information supplied by the Internal Revenue Service, the SSA would notify eligible beneficiaries that they are automatically enrolled in the program unless the SSA received information that indicated they were not qualified.

At the same time, the SSA is testing strategies in Massachusetts and 11 communities in six other states to streamline the program’s outreach enrollment strategies.

The April GAO report found that 2.2 million Medicare beneficiaries are not receiving the cost-sharing assistance for which they are eligible under the federal Qualified Medicare Beneficiary (QMB) or Specified Low-Income Medicare Beneficiary (SLMB) programs. About 68% are women and 32% are 80 years of age or older. Enrollment in the QMB or SLMB programs represents only about 57% of those eligible, the GAO found.

The Health Care Financing Administration "shares GAO’s concern" about the QMB and SLMB enrollment and is making access to eligibles "a high priority," said HCFA administrator Nancy-Ann DeParle in response to the GAO report. The administration is developing a resource guide to help states identify and enroll those eligible for both Medicare and Medicaid, the so-called dual eligibles.

About 2.5 million elderly people on Medicare also meet their states’ requirements to be eligible for full Medicaid benefits. While Medicare is primary in these instances, Medicaid adds crucial coverage for prescription drugs and long-term care, which generally is not available under Medicare. Those with full Medicaid benefits also receive payment for Part B (outpatient) Medicare coverage.

The QMB and SLMB programs are among a constellation of Medicaid programs for the elderly who are not eligible for full Medicaid benefits but who still need assistance with their health care expenses. Under QMB, state Medicaid programs are responsible for the Medicare premiums, deductibles, and coinsurance for Medicare beneficiaries who have incomes at or below 100% of the federal poverty level, or about $8,050 annually in 1998 for an individual. The SLMB program is for those who are slightly better off; it requires Medicaid to pick up the Medicare part B premium, but not the deductibles or coinsurance, for beneficiaries with incomes above 100% but below 120% of the federal poverty level.

Although the benefits under QMB and SLMB seem modest—the monthly part B Medicare premium in 1998 was $43.80—the programs "aid in the financial well-being of low-income Medicare beneficiaries," says an analysis by AARP and Princeton, NJ-based Mathematica Policy Research. The report, co-written by Ms. Lamphere and Mathematica’s Margo Rosenbach, PhD, notes that the average elderly person living in poverty spends 35% of his or her income on out-of-pocket health care costs. The range extends from 8% for those with full-year Medicaid coverage to 50% for those without any Medicaid protection at all.

Past efforts disappointing

The current demonstration projects aren’t the federal government’s first attempt to rectify what the AARP calls "very low" participation rates in QMB and SLMB. A 1994 law required HCFA to get from new Medicare beneficiaries enough information to determine their eligibility for QMB and SLMB and give this information to state Medicaid programs. In a February 1999 letter to state Medicaid directors, HCFA officials encouraged nonparticipating states to join the 19 that regularly receive the agency’s "leads data," the result of its screening for QMB and SLMB eligibles.

Contact Ms. Lamphere at (202) 424-3902. GAO report HEHS-99-61, "Low-income Medicare Beneficiaries: Further Outreach and Administrative Simplification Could Increase Enroll ment," can be ordered from GAO at (202) 512-6000 or downloaded from the Web at