Medicare premium buy-in programs: results of SSA demonstration projects

Three programs known collectively as the Medicare buy-in programs are available to pay Medicare Part B premiums and, in some cases, other medical expenses for certain low-income individuals. The Health Care Financing Administration administers those programs, with most functions performed by the states. The Social Security Administration (SSA) plays an indirect role in the buy-in programs: with certain exceptions, people who qualify for Medicare and hence for buy-in are beneficiaries of Social Security retirement or disability programs. SSA is often cited as an agency that might be able to increase enrollment in the buy-in programs through outreach to its beneficiaries and by acting as an intermediary in the enrollment process. The three buy-in programs have different requirements for eligibility. The Qualified Medicare Beneficiary (QMB) program includes individuals who have Part A Medicare benefits and whose income does not exceed 100 percent of federal poverty guidelines. People in the Specified Low-Income Medicare Beneficiary (SLMB) program are individuals who would otherwise be QMBs but whose income is more than 100 percent but less than 120 percent of poverty guidelines. People in the Qualified Individual (QI) program are those who meet the other criteria but whose income is less than 175 percent of poverty guidelines. Various reports and studies by government agencies and advocacy organizations conclude that the buy-in programs are not reaching many of the people who are eligible. Low enrollment appears to be a particular issue for the SLMB and QI programs. States have tried various outreach efforts, but the effectiveness of those efforts has not been adequately assessed. In 1998, Congress mandated that SSA conduct a demonstration project to determine how to increase participation in the buy-in programs. The project tested six different administrative models in which outreach letters were sent to potential beneficiaries asking them to contact SSA and then be screened for eligibility and referred for enrollment. SSA was able to screen about 7.1 percent of letter recipients for buy-in eligibility: 4.2 percent were potentially eligible for the programs based on income and resources, and 3.7 percent enrolled in a buy-in program. An evaluation of the probability that letter recipients would contact SSA to be screened found that: Among the elderly, older individuals were less likely to be screened but more likely to enroll. Among the disabled, older individuals were more likely to be screened but less likely to enroll. The disabled were less likely to be screened but more likely to enroll. Individuals with higher Social Security benefits were more likely to be screened but less likely to enroll. Women were more likely to be screened and to enroll. Being married did not appear to affect screening but negatively affected enrollment. Individuals with a preference for materials in Spanish were much more likely to be screened and enrolled. In some of the demonstration sites, enrollment in a Medicare+Choice plan increased the probability of being both screened and enrolled. SSA conducted a survey of some people who did not respond to the outreach letter. Most of those from whom explanations of the nonresponse were obtained had not responded because they were not eligible on the basis of their income or resources. If SSA were to reproduce the demonstrations in a nationwide outreach effort, a national mailing would include nearly 20 million individuals. If response rates were similar to those seen in the 1999 demonstrations, outreach would produce over 740,000 new buy-in enrollees. That number might be increased modestly by conducting additional outreach efforts in conjunction with the mailing.