Medicaid Assistance for Medicare Beneficiaries with Low Incomes

Background

Two types of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. coverage are available for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries with low incomes:

  • coverage of the full MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefit package and financial assistance with MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). premiums and cost-share, and
  • financial assistance only with MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). premiums (in some cases) and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services..

Eligibility for full MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefits and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. assistance: There are two eligibility pathways for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries with low incomes to receive the full MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefit package plus cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. assistance. First, federal law generally requires states to cover older adults with low incomes who receive cash assistance through Supplemental Security IncomeThe SSI program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled., commonly referred to as SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled.. An exception to this general rule gives states the option—called the Section 209b option—to use their state general assistance criteria, in place since 1972, instead of federal SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. rules to determine eligibility under this pathway.

The second eligibility pathway is the optional MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. medically needy programs. This is for individuals who have exhausted their financial resources on their health and long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. needs. States that use the Section 209b options are required to allow people to “spend down” to medically needy income and asset levels.

Other eligibility for full MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefits for older adults: Federal law allows states to provide state-funded cash supplemental payments (SSP) to individuals to supplement their SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. income. These payments can be made to all individuals receiving SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled., or they may be targeted to certain groups, like those receiving care in group homes or assisted living facilities. States may also make SSPs available to individuals whose income exceeds SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. standards. States are allowed to extend full MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. coverage to individuals who receive SSPs. In cases where a person receives SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. and SSP, if a cost-of-living increase in their SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. payment causes them to be over income for receipt of SSP, they remain eligible for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. under the Pickle Amendment. That amendment requires these states (e.g., those that extend MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. eligibility to people on SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled., people receiving SSP, or both) to disregard cost-of-living increases to SSIThe Supplemental Security Income (SSI) program was designed to reduce poverty by providing basic cash support to people with low income and assets below certain thresholds who are aged, blind, or disabled. payments.

Older adults may also qualify for MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. under the nursing facility or special income rule pathways. (see also Financial Protections and Choice for Medicaid Participants and Their Families for an explanation of these pathways).

Medicare Savings ProgramsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.: MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries who are not eligible for full MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. benefits may qualify for one of three Medicare Savings ProgramsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. (MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.). Under the MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS., MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. pays some or all of the individual’s MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.. The MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. have three categories, each with its own income, asset, and coverage rules (Figure 7-2).

The Qualified Medicare BeneficiariesThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. (QMB) Program is a MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. initiative intended to give certain MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries with low incomes full access to their MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). benefits by paying their premiums, deductibles, and copayments (Figure 7-2). State MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. programs have the option to pay for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Part C Medicare AdvantageMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. (MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D.) for those MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries who elect to enroll in MAMedicare Advantage (MA) health plans are offered by private Medicare approved companies as an alternative to Original Medicare. Medicare pays these companies a fixed amount per enrollee per month to provide benefits for Parts A, B, and (usually) D. plans covering Medicare Part AThis program covers inpatient hospital care, short stays in a skilled-nursing facility, home health care under certain conditions, and hospice care. Those who qualify for Medicare pay no premium for Part A. and B benefits and mandatory supplemental benefits. Regardless of whether the state MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. agency opts to pay the Part C premium, the QMB is not liable for any coinsuranceA form of health care cost sharing in which a percentage of covered expenses must be paid by the insured. In contrast, a copayment is a specific dollar amount that must be paid for a specific service. or deductibles for Part C benefits.

States may use less restrictive income-counting rules to raise income and asset limitsThe value of assets a person or family can have and still qualify for public assistance benefits. for their MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.. This makes more people eligible for both MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. and the MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Part D Low-Income Subsidy program. Although MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. do not pay cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Part D, people enrolled in MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. are also eligible for the Low-Income Subsidy program.

Figure 7-2: MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Protections for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Beneficiaries with Low Incomes

Medicaid Protections for Medicare Beneficiaries with Low Incomes

Payment issues for Qualified Medicare BeneficiariesThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. (QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments.): Federal law bars MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). providers from billing QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. for the difference between what they are paid and what they charge/ This is a practice known as balance billingWhen a provider bills a patient for the difference between the provider’s charge and the amount paid by an insurer or Medicare. Medicare sets limits on the amount that a patient can be required to pay.. The law states that the amount of money paid by MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and a state (if any) for health services provided to a QMB must be considered payment in full. Providers are also prohibited from billing QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services., including deductibles, coinsuranceA form of health care cost sharing in which a percentage of covered expenses must be paid by the insured. In contrast, a copayment is a specific dollar amount that must be paid for a specific service., and copayments. QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. have no legal obligation to make further payment to a provider (including managed care organizations) for Part A or Part B cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services..

In theory, QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. should have full access to MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Parts A and B providers without any cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. liability. MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). would pay its portion, and MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. would cover the remainder of the MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant).-approved amount that reflects the beneficiary’s cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. obligation. However, in practice, the QMB Program fails to fulfill its promise because federal law allows states to cap their contributions to MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. at the much lower MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. provider-payment rates.

The prohibition on balance billingWhen a provider bills a patient for the difference between the provider’s charge and the amount paid by an insurer or Medicare. Medicare sets limits on the amount that a patient can be required to pay. of QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. has led providers to complain that they are not adequately reimbursed by MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets.. This could compromise beneficiary access. In addition, some providers continue to balance-bill beneficiaries even though this practice is contrary to federal law. Providers who inappropriately balance-bill QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. are subject to sanctions. They are also violating their provider agreement with the Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services.

Advocates report that QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. frequently go without needed care because they cannot find specialists, mental health professionals, and other providers willing to serve them because of the crossover payment issue.

Payment procedures create another barrier to provider participation because many states, despite the Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services guidance to the contrary, require MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). providers seeking copayments to go through cumbersome application procedures to receive them. States often reject reimbursement requests outright if providers are not also enrolled in MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets..

QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. who are able to find MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). providers may face demands for copayments that they do not owe. Protections against balance billingWhen a provider bills a patient for the difference between the provider’s charge and the amount paid by an insurer or Medicare. Medicare sets limits on the amount that a patient can be required to pay. are not well understood by providers. Though both state and federal authorities have enforcement remedies available, they are rarely used. The practical impact of these many deficiencies is that QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. find that when they need to use their benefit, it is largely unavailable to them.

MEDICAID ASSISTANCE FOR MEDICARE BENEFICIARIES WITH LOW INCOMES: Policy

MEDICAID ASSISTANCE FOR MEDICARE BENEFICIARIES WITH LOW INCOMES: Policy

Adequate funding

Medicare Savings ProgramsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. (MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.) should be fully funded to ensure that all eligible individuals have financial access to benefits.

Enrollment maximization

Federal and state governments should work together to identify strategies to maximize enrollment in MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS..

Federal and state governments should ensure that MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries and social services personnel are adequately informed of the program’s eligibility requirements and benefits.

Modifying or eliminating the asset limits

Congress should eliminate the asset test for MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS. or make it less restrictive.

Alternatively, states should use existing statutory flexibility to eliminate or modify asset tests. A state can use less restrictive resource requirements by disregarding all resources or increasing what can be excluded from countable assets.

Income Test

Where fiscally feasible, states should take advantage of the opportunity to increase income eligibility for their MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.. A state can use less restrictive requirements by increasing what can be excluded from countable income.

Increase enrollment

State governments should be required to monitor Qualified Medicare BeneficiariesThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. (QMB), Specific Low-Income MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). Beneficiary (SLMBSLMB eligibility extends to all Medicare beneficiaries with incomes between 100 percent and 120 percent of the federal poverty level and who meet a strict asset test. The state’s Medicaid program will then pay the Part B premium. ), and Qualifying Individuals (QI) participation rates and report enrollment rates to the federal government on an ongoing basis. States should also be required to develop and implement outreach and enrollment activities in areas with low QMB, SLMBSLMB eligibility extends to all Medicare beneficiaries with incomes between 100 percent and 120 percent of the federal poverty level and who meet a strict asset test. The state’s Medicaid program will then pay the Part B premium. , and QI enrollment. States should give special attention to access problems in rural areas. Federal and state policymakers should work together to identify ways to use existing data sources to identify and enroll MSPPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.-eligible individuals.

 

Medicaid Buy-In

MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. buy-in protections for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). premiums, deductibles, and coinsuranceA form of health care cost sharing in which a percentage of covered expenses must be paid by the insured. In contrast, a copayment is a specific dollar amount that must be paid for a specific service. should be extended to MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). beneficiaries with income up to 200 percent of the federal povertyThe federal government defines “poverty” as income below specific thresholds. These thresholds are adjusted annually for inflation and vary according to family size and the age of the head of the family. level.

 

Increase Outreach and Education

The Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services, the Social Security Administration, and other federal agencies with jurisdiction over programs for older adults with low incomes should fund state outreach, education, and enrollment efforts for the MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.. They should lead efforts to simplify the application process.

Federal agencies with jurisdiction over programs for older adults with low incomes, including the Social Security Administration, should ensure that the individuals they serve are aware of MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets., especially its QMB, SLMBSLMB eligibility extends to all Medicare beneficiaries with incomes between 100 percent and 120 percent of the federal poverty level and who meet a strict asset test. The state’s Medicaid program will then pay the Part B premium. , and QI protections. These agencies should lead efforts to develop intensive outreach initiatives and simplified application processes. Outreach efforts that have shown to be more effectively or efficiently performed at the federal level should be implemented by the appropriate federal agencies and funded adequately.

States should:

  • simplify their administrative procedures so that eligible beneficiaries will be more likely to enroll in MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.;
  • develop simplified applications and consumer-friendly application sites, institute passive renewal processes, and eliminate burdensome documentation requirements;
  • conduct innovative grassroots outreach to educate seniors about MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets., particularly the MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS.—innovations should include new outreach methods and sites, including by involving volunteer organizations; and
  • make use of all available data to identify and enroll people eligible for MSPsPrograms that provide financial assistance with premiums and/or cost-sharing to low-income Medicare beneficiaries who meet income and asset criteria. These programs are administered by State Medicaid agencies, with federal oversight by CMS..

Payment of full cost-sharing

Federal and state governments should examine the extent to which MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets.’s failure to pay the full MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). deductibles and copayments for QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. threatens access to care. If access is compromised, states should be required to pay the full cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. obligation even if it exceeds the MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. payment rate.

 

Enforcement of the prohibition on balance billing

Federal and state governments should actively enforce the protections against the balance billingWhen a provider bills a patient for the difference between the provider’s charge and the amount paid by an insurer or Medicare. Medicare sets limits on the amount that a patient can be required to pay. of Qualified Medicare BeneficiariesThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. by providers.

Federal and state governments should develop and implement strategies to identify QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. who receive bills from providers. They should educate both beneficiaries and providers about the federal prohibition on balance billingWhen a provider bills a patient for the difference between the provider’s charge and the amount paid by an insurer or Medicare. Medicare sets limits on the amount that a patient can be required to pay..

Improved identification cards

Federal and state governments should collaborate to improve identification cards for QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments. that include clear instructions for providers on rules for serving QMBsThe QMB Program is a Medicaid initiative that provides low-income Medicare beneficiaries full access to Medicare benefits by paying their premiums, deductibles, and copayments..