How Medicare Eligibility Enhancement Services Can Help Expand Coverage for Medicaid Members

The past few years have been tumultuous for the healthcare system and have caused more uncertainty and even fear among Americans relying on federal and state benefits. Unfortunately, many older Americans may not be taking advantage of all the sources of healthcare coverage available to them.

Medicaid members aged 65 and older may not have Medicare coverage even though they may meet all Medicare eligibility guidelines. By federal law, Medicaid must remain the payer of last resort, so securing Medicare benefits or other forms of insurance for Medicaid members is a must. But Medicaid members may be unaware or misinformed regarding Medicare eligibility guidelines, and they may be afraid of losing current Medicaid benefits.

What’s more, states may miss populations of Medicaid members who should qualify as dually eligible for Medicaid and Medicare. Medicaid members lose out on valuable Medicare benefits, and state Medicaid programs continue to pay for healthcare services that should be covered by Medicare. This can cost states significant amounts of money.

Older Americans may not have successfully completed the complex Medicare application and enrollment process with the Social Security Administration (SSA), or they may not have even tried. They may not know that Medicaid and Medicare can work together to provide enhanced care. They may have received inaccurate information – or even been turned away – due to confusion on the coordination between Medicaid and Medicare benefits.

Individuals are then denied earned benefits that are necessary to maintain an adequate standard of living, and the costs of these missed benefits are shifted from federal responsibility to state Medicaid and other health and human service programs.

Errors in Payments Due to Challenging Processes

SSA has acknowledged errors in determining entitlement to Social Security cash benefits and Medicare, specifically among certain populations of Medicaid members with disabilities. As states continue to provide Medicaid coverage – and in some cases state cash benefits – to individuals who should be receiving federal benefits, these errors continue to force states to issue unnecessary payments.

States may also experience discrepancies in their Medicare Part A and B premium payments on behalf of qualifying individuals through the Medicare Savings Programs, commonly known as Medicare Buy-In. Medicare Buy-In administration may be spread across Medicaid and other health and human service programs, and eligibility determination, payment, and financial management activities may reside in separate units. With so many parties involved at the state and federal levels, discrepancies related to eligibility and premium billing frequently occur, resulting in more payment inaccuracies. 

Many Medicaid programs don’t have the specialized expertise, resources, or time to fully evaluate their populations for potential Medicare benefits—and may not identify additional opportunities for enhanced Medicare savings. As a result, your state can miss populations of Medicaid members who may qualify as dually eligible, lose out on potential Medicare cost savings, or overpay for Medicare premiums. This can cost members valuable benefits and states millions of dollars.

Using Data Analysis and Specialized Service

ForHealth Consulting™ at UMass Medical School uses a specialized data-driven and customer-focused approach to identify Medicaid members who appear eligible for, but are not enrolled in, Medicare; pinpoints data discrepancies and barriers preventing access to full Medicare benefits; and develops customized strategies to resolve issues and increase member access to full Medicare coverage.

We apply our deep understanding of federal rules and proprietary software tools to help state agency partners achieve meaningful results. Our Medicare eligibility and coordination methods go beyond those performed by states or other vendors.

Our Medicare data assurance review utilizes proprietary data integration techniques to identify and validate new Medicare coverage information for Medicaid members. We use this same level of expertise in correcting Medicare and disability entitlement payments for those missed by SSA, ensuring that state payments of Medicare premiums are accurate, and recovering overpayments.

In addition, our Medicare enrollment support facilitates Medicare enrollment for over-65 Medicaid members, including comprehensive, one-on-one customer service support. We go beyond just regular service— providing services from scheduling appointments with SSA, to ensuring translation services, to following-up with members and SSA to achieve successful Medicare enrollment.

Our approach sets us apart, achieving more significant results.

  • In one state, ForHealth has achieved over $82M in cost savings since FY15 by identifying previously missed Medicare coverage among Medicaid members.
  • Through ForHealth’s Medicare Enrollment Support activities, over 8,500 Medicaid members have been enrolled in Medicare since FY14, resulting in over $102M in new cost savings for one state.
  • Our strategies have achieved a 96% Medicare enrollment rate for Medicaid members whose cases were processed by SSA.
  • Over 98% of Medicaid members agree to apply for Medicare when engaged by phone and supported by our team.

The end result of these efforts is a win for both parties. In many cases, Medicaid members may access Medicare benefits at no cost, gain an expanded provider network, and qualifying relatives of members may also be eligible to receive cash and Medicare benefits. New Medicare enrollment of Medicaid members and corrections and refunds of incorrect Medicare premium payments reduces future costs for state Medicaid programs and creates future revenue opportunities.

ForHealth Consulting presented on TPL approaches, including about our Medicare Eligibility Enhancement Services, and the latest trends, at the recent Medicaid Enterprise Systems Conference. Review the workshop presentation, and learn more about how our best practices can better serve members and save Medicaid programs money and resources.

Learn more about how we can help.