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Comments on the proposed rule on the Medicare Prescription Drug Benefit

By: Study Panel on Medicare and Medicaid Dual Eligibles
Published: October 2004

Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS 4068-P
P.O. Box 8014
Baltimore, Maryland 21244-8014

Dear Sir or Madam:

In July 2003, the National Academy of Social Insurance (NASI) formed an expert study panel to examine ways the federal government could increase enrollment in the Medicare Savings Programs (MSP). NASI established the study panel in response to survey reports that many Medicare beneficiaries, perhaps as many as 40 percent, of those eligible to receive a subsidy for the MSP are not enrolled. After the passage of the Medicare Modernization Act (MMA) in November 2003, the study panel decided to expand its scope to include coordination issues between the MSP and the low-income subsidy for the new Medicare prescription drug benefit. Through this letter, the study panel is offering its comments on the proposed rule on the Medicare Prescription Drug Benefit, published in the Federal Register on August 4, 2004.

NASI is a nonprofit, nonpartisan membership organization whose mission is promoting understanding and informed policymaking on social insurance and related programs through research, public education, training, and the open exchange of ideas. The views expressed in these comments do not represent an official position of NASI, which does not take positions on policy issues, or its funders. Further, these comments reflect the personal views of the Study Panel on Medicare and Medicaid Dual Eligibles, and not the official views of the organizations with which they are affiliated, or the views of the Commonwealth Fund, whose generous support made this work possible.

As chairperson, I am sending these comments on behalf of the study panel. The other members of the panel are: Barbara Cooper, Senior Program Officer, The Commonwealth Fund, Elizabeth Cusick, independent consultant, Ruben King-Shaw, President, UBC Solutions, Ken Nibali, independent consultant, Cathy Rossberg, Vice President, Government Relations, Amerigroup, and Judith Waxman, Vice President for Health and Reproductive Rights, National Women's Law Center. I serve as President of the Alliance of Community Health Plans. NASI selected the members of the study panel to represent diverse viewpoints and expertise. All of the study panel members have experience in administering Social Security, Medicare or Medicaid, either in the federal or state governments. The panel has also benefited from technical assistance provided by the staff at the Social Security Administration (SSA) and the Centers for Medicare and Medicaid Services (CMS).

Coordination between the Medicare Prescription Drug Program Low Income Subsidy and the Medicare Savings Program.

The study panel's comments address only issues designed to help ensure that all Medicare beneficiaries who are eligible for the MSP are enrolled, and to establishing the best possible coordination between the low-income subsidies in the prescription drug program and the MSP. As former public administrators, the study panel is acutely aware of the enormous challenges facing CMS and SSA in preparing to implement a highly complex law and new program within a very short time period. The study panel believes that CMS and SSA should appropriately focus their attention and resources on implementing the new law. In light of that, these recommendations are not designed to impede either agency in any way, or divert scarce resources, from implementing the MMA. The panel will consider more comprehensive recommendations to better coordinate the two programs in its final report, scheduled for release in 2005.

Better Targeting of the Section 1144 Mailings

Section 1144 of the Medicare, Medicaid, and S-CHIP Benefits and Improvements Act of 2000 (BIPA) instructed SSA to annually identify beneficiaries potentially eligible for MSP, notify them about the programs, and send copies of the list of the identified eligibles to the appropriate state agencies. However, SSA often does not have current information about the income and assets of Medicare beneficiaries because approximately 75 percent of Social Security beneficiaries file for benefits either before turning 65, or are disabled individuals who have a 24-month waiting period before receiving benefits. When applicants file for Social Security benefits, SSA is required to screen applicants them for potential eligibility for the Supplemental Security Income (SSI) program, which is means-tested. Because of the time lag between when SSA takes information about income and assets and when most beneficiaries start receiving Medicare benefits, SSA's information about income and assets is not current. As a result, SSA has not been able to target accurately the mailings required under Section 1144 just to those likely to be currently eligible for the MSP, and has mailed a significantly larger number of letters than it might have had to if it had more current income and asset data. For example, SSA mailed about 16.5 million letters in 2002.

Beneficiaries who apply for the low-income drug subsidies will provide SSA with current information about their income and assets. Having this information will enable SSA to target the Section 1144 mailings much more accurately, and will provide states with more accurate information for their follow-up efforts. The study panel recognizes that computer programming work will be needed to generate these notices to the states, but does not believe it will impose an undue burden on SSA. The panel recommends that SSA use the information provided in these applications in preparing the Section 1144 mailings.

Providing Income and Asset Information about MSP-Eligibles to the States

In addition to using the data to better target the Section 1144 mailings, SSA could provide the actual data about PDP-Eligibles to the states for their analysis and follow-up. This approach has several advantages. States would benefit from current information about income and assets to assist them both in identifying potential MSP-Eligibles and also in determining eligibility for the MSP. The study panel believes that it could provide sufficient information to the states for them to make MSP eligibility, if the states so chose. It would also impose fewer burdens on beneficiaries, because they would not be required to provide the same information twice. The panel recommends that SSA provide this information to the states.

The panel is aware that release of this information to the states might raise privacy concerns. The study panel recommends resolution of privacy issues so that this information can be shared with state agencies.

One option to respond to potential privacy concerns is to allow applicants for the low-income drug subsidies to consent to sharing information with their state agency to assist the state in determining whether they are eligible for the MSP. The panel recommends that a section be added to the low-income drug subsidy application to allow SSA to share information with the states for the purpose of determining beneficiaries' eligibility for the MSP.

Thank you for considering these comments.

Sincerely,

Jack Ebeler
Chairperson, NASI Study Panel on Medicare and Medicaid Dual-Eligibles