Low-Income Medicare Beneficiaries

In 1995, premiums, deductibles, and coinsurance cost single persons at the federal poverty level 10 percent of income, and married couples, 15 percent. State Medicaid programs helped them bear their costs through the congressionally enacted Qualified Medicare Beneficiary (QMB) program, the Specified Low-Income Medicare Beneficiary (SLMB) program, and the Qualifying Individuals program. In 1996, about 43 percent of the potentially eligible Medicare beneficiaries were not enrolled in either QMB or SLMB. Enrollment in these programs is relatively low for Medicare beneficiaries who are white, widowed or married, or have Medicare coverage because of age rather than disability. Many potential recipients do not enroll because they do not know the programs exist, believe they are only for "poor people," fear that the state will try to recover payments made to them from a surviving spouse or children, or are unwilling to accept what they think of as welfare. Moreover, the application process is burdensome and complex, and the states' cost-sharing obligations limit their incentives to notify and enroll eligible individuals. Efforts to increase enrollment include a Social Security Administration demonstration project, state outreach and enrollment efforts through their State Children's Health Insurance Programs, and efforts by the Health Care Financing Administration under the Government Performance and Results Act.

GAO noted that: (1) although enrollment in QMB and SLMB has increased since the programs were implemented, many potentially eligible Medicare beneficiaries are not enrolled in these programs; (2) in 1996, about 2.2 million of an estimated 5.1 million potentially eligible Medicare beneficiaries--about 43 percent--were not enrolled in either QMB or SLMB; (3) in general, the characteristics of QMB and SLMB enrollees are similar to individuals who are eligible but do not enroll, placing them among the most vulnerable Medicare beneficiaries; (4) in addition to having low income, these individuals tend to have health conditions affecting their capacity to perform various activities; (5) the groups differ in some respects, however, as beneficiaries who are eligible but not enrolled are more likely to be 80 years of age or older or to have no health insurance coverage other than Medicare; (6) GAO's analysis also indicates that QMB and SLMB enrollment can vary by specific demographic characteristics; (7) for example, enrollment is relatively high among beneficiaries who are disabled, in poor health, are members of minority groups, are separated, or have never married; (8) conversely, enrollment is lower for beneficiaries who are white, widowed, married, or have Medicare coverage because of age rather than disability; (9) advocates for low-income elderly and state officials GAO interviewed attributed persistently low QMB and SLMB enrollment to limited program awareness among beneficiaries and the programs' administrative complexity; (10) potentially eligible individuals are perceived to simply be unaware of these programs, their benefits, or their eligibility criteria; (11) also, low enrollment in these programs is thought to result from state cost-sharing obligations that limit states' incentives to notify and enroll eligible individuals; (12) recently, the Health Care Financing Administration (HCFA) and the Social Security Administration have initiated efforts aimed at identifying strategies for increasing QMB and SLMB enrollment; (13) HCFA has established a task force that is in the process of identifying targets for increased enrollment and strategies for reaching these goals; and (14) a number of states GAO contacted have taken steps to simplify their application and enrollment processes, and advocates and state officials who GAO interviewed suggest that expanded administrative simplification efforts in conjunction with more creative and targeted outreach could increase QMB and SLMB enrollment.