Medicare Eligibility Enhancement

Medicare represents the largest single source of Third Party Liability (TPL) savings for state Medicaid programs. Dual-eligible recipients, who receive both Medicaid and Medicare benefits, represent a significant population for state Medicaid programs — 35% of Medicaid spending, according to The Centers for Medicare & Medicaid Services (CMS). Recognizing the critical role of Medicare for state Medicaid programs, we have applied a research-based approach to developing and implementing Medicare savings initiatives that have yielded results to benefit many states and the populations they serve. Our goals are to:

  • Ensure that Medicaid recipients receive all Medicare and Social Security benefits to which they are entitled
  • Support Medicaid as the Payer of Last Resort by securing Medicare as the primary payer

Our staff possesses a highly specialized understanding of Social Security Administration (SSA) and CMS eligibility policies and procedures, and the ways in which federal eligibility processes impact Medicaid recipients. We utilize this knowledge in conjunction with technical expertise in federal data sets to evaluate the accuracy of federal benefit determinations, and identify federal discrepancies and errors potentially impacting state cost savings and recovery efforts. Our initiatives include:

Our Results

  • In 2009, based on our findings, the SSA corrected a systemic flaw in their eligibility systems that resulted in the CMS refunding over $250 million to states for erroneous Medicare Part A premiums charged to states since the 1990s. Subsequently, we identified and provided examples of further discrepancies in the Part A premium billing process, ultimately leading to a second systemic fix implemented by the CMS in May 2014.
  • Currently, the SSA is in the process of implementing another benefit determination correction for Massachusetts based on findings we reported in 2010; the value of the correction is expected to exceed $15 million for Massachusetts alone.
  • We have identified the same SSA eligibility determination flaw in two other states and estimate the potential savings value for those states at over $55 million.
  • We served as the lead technical support for the 33-state Special Disability Workload (SDW) coalition, seeking $4 billion in net payments as a result of an SSA error that dates back to 1974.
  • We are currently working with three SSA Regional Offices and the CMS Central Office to correct instances of missed Medicare entitlement and benefits for Medicaid populations across three states. The annual gross cost savings resulting from these corrections for the three state Medicaid programs is estimated at $70 million to $75 million.