Many low-income Medicare beneficiaries receive assistance from  Medicaid to pay Medicare’s cost-sharing requirements. MIPPA included several new requirements aimed at eliminating barriers  to MSP enrollment. Specifically, MIPPA required SSA to, beginning  January 1, 2010, transfer data from LIS applications, at the option of  applicants, to state Medicaid agencies, and it required state Medicaid  agencies to use the transferred information to initiate an MSP application. SSA was also required to make information on MSPs available to those  potentially eligible for LIS, coordinate outreach for LIS and MSPs, and  train staff on MSPs.included a number of other provisions related to MSPs. SSA Transferred over 1.9 Million Applications to States, Made Information on MSPs Available to Potentially Eligible Individuals, and Trained Staff

As required by MIPPA, SSA began transferring applications in January  2010, and SSA reported transferring over 1.9 million applications to states  between January 4, 2010, and May 31, 2012. SSA Spent about $12 Million in the First 3 Years and Reported That Implementing the Requirements Did Not Significantly Affect SSA’s Workload

In fiscal years 2009 through 2011, SSA spent about $12 million to  implement the MIPPA requirements. Of the $24.1 million appropriated by  MIPPA for the initial costs of implementing the requirements, SSA spent  $9.2 million combined for fiscal years 2009 and 2010 ($4.5 million and  $4.7 million respectively). In  fiscal year 2011, SSA spent about $2.5 million of the $3 million  appropriated under MIPPA for the ongoing administrative costs of  carrying out the requirements. Estimated MSP Enrollment Increased from 2007 through 2011 with the Largest Increases Occurring after the Requirements Took Effect

Using CMS data, we estimated that MSP enrollment increased each year  from 2007 through 2011. The largest increases in MSP enrollment  occurred in 2010 and 2011 (5.2 percent and 5.1 percent respectively), the  first 2 years that the MIPPA requirements were in effect. A number of factors may have contributed to the higher levels of growth in  MSP enrollment in 2010 and 2011, including SSA application transfers  and outreach, other MIPPA provisions and related changes to state  policies, and the economic downturn. In response to our survey of state  Medicaid officials about the effects of the application transfers on  MSP enrollment, officials from 28 states reported that MSP enrollment  has increased as a result of the application transfers. While there are no nationwide data that demonstrate the effects of the  SSA application transfers on MSP enrollment, 3 of the 6 states we  contacted to supplement our survey tracked some information on the  outcomes of applications transferred by SSA.application transfers from SSA in 2011, Arizona reported enrolling  about 800 of 16,000 applicants; Louisiana reported enrolling about   As a result of the  3,300 of about 21,800 applicants; and Pennsylvania officials reported  enrolling about 16,000 of 37,500 applicants. For example, these  enrollees may have instead enrolled by applying directly through the  state. The extent to which the SSA application transfers required system  changes or affected workload may have depended on whether the state  treated the transferred information as verified. Though CMS policy allows  states to treat the information in the transferred applications as verified, in  response to our survey, officials from 35 states reported requiring  applicants to reverify some or all of the information before the state would  determine eligibility for MSPs. Specifically, of the three  states that we contacted that accepted SSA’s verification of the  application information, two states reported being able to enroll some of  the transferred applicants with little to no work required of caseworkers. This verification process included multiple  steps by states and applicants. Differences in how SSA and states count income and assets for LIS  versus MSPs may have driven states’ choices to require further  verification of information in the transferred applications. The guidance  reminded states that they have the option to align their definition with  SSA’s, and noted that doing so would expand eligibility for MSPs to more  people and reduce states’ administrative burden in processing the  applications transferred by SSA. Aligning the methods for determining  income and assets for MSPs with those of LIS is an option currently  available to states, and some states have used that flexibility. SSA stated, in an e-mail, that the report accurately  describes its implementation of the requirements. Appendix I: GAO Methodology for Estimating Change in Medicare Savings Program Enrollment

To describe the change in Medicare Savings Program (MSP) enrollment  from 2007 through 2011, we used data from the Centers for Medicare &  Medicaid Services (CMS) to estimate annual enrollment and the change  in annual enrollment over that period.
Why GAO Did This Study

Congress established four MSPs and the LIS program to help low-income beneficiaries pay for some or all of Medicares cost-sharing requirements. Historically low enrollment in MSPs has been attributed to lack of awareness about the programs and cumbersome enrollment processes through state Medicaid programs. MIPPA included requirements for SSA and state Medicaid agencies aimed at eliminating barriers to MSP enrollment. Most notably, MIPPA created a new pathway to MSP enrollment by requiring SSA, beginning January 1, 2010, to transfer the information from a LIS application to the relevant state Medicaid agency, and the state must initiate an application for MSP enrollment. MIPPA also required GAO to study the effect of these requirements. This report describes (1) SSAs implementation of the requirements; (2) how MSP enrollment levels have changed from 2007 through 2011 and the factors that may have contributed to those changes; and (3) the effects of the MIPPA requirements on states administration of MSPs.
GAO reviewed documents and data on SSAs efforts to transfer applications and implement other MIPPA requirements, analyzed MSP enrollment data from CMS, surveyed Medicaid officials from the 50 states and the District of Columbia, and contacted officials from 6 states selected, in part, because they accounted for over 20 percent of MSP enrollment.

What GAO Found

The Social Security Administration (SSA) took a number of steps to implement the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requirements aimed at eliminating barriers to Medicare Savings Program (MSP) enrollment and spent about $12 million in fiscal years 2009 through 2011 to do so. SSA reported transferring over 1.9 million Low-Income Subsidy (LIS) program applications to state Medicaid agencies between January 4, 2010 and May 31, 2012. SSA also took steps to make information available to potentially eligible individuals, conduct outreach, and train SSA staff on MSPs. In fiscal years 2009 and 2010, SSA spent $9.2 million of the $24.1 million appropriated by MIPPA for initial implementation costs, and in fiscal year 2011, SSA spent about $2.5 million of the $3 million appropriated by MIPPA for ongoing administrative costs. SSA officials told GAO that implementing the MIPPA requirements has not significantly affected its overall workload and that SSA expects funding provided under the law to be sufficient to carry out the requirements.
Using data from the Centers for Medicare & Medicaid Services (CMS), GAO estimates that MSP enrollment increased each year from 2007 through 2011. The largest increases occurred in 2010 and 2011 (5.2 percent and 5.1 percent respectively), the first 2 years that the MIPPA requirements were in effect. Several factors may have contributed to the higher levels of growth in MSP enrollment during these 2 years, including SSA application transfers and outreach, other MIPPA provisions related to MSPs, and the economic downturn. For example, while there are no nationwide data demonstrating the effects of the SSA application transfers, officials from 28 states reported that MSP enrollment had increased as a result of the transfers.
Officials from most of the six states GAO contacted to supplement its survey reported that the SSA application transfers led to changes in eligibility systems and had increased the state's workload, that is, the time spent processing MSP applications. The extent to which the application transfers resulted in system or workload changes may have depended on whether states accepted SSA's verification of the information transferred, as allowed under CMS policy. In response to GAO's survey, officials from 35 states reported that the state required the applicant to reverify at least some of the information. GAO found from interviews with officials from selected states that requiring reverification from applicants included multiple steps by the state and applicant. In contrast, officials from two states that accepted SSA's verification of the information told GAO that the state was able to enroll some of the applicants transferred by SSA with little to no work required by caseworkers. Differences in how SSA and states count income and assets when determining eligibility for LIS versus MSPs may have driven states' decisions to require verification from applicants. States have the flexibility under federal law to align methods for counting income and assets for MSPs with those for LIS and doing so may reduce the administrative burden of processing the transferred applications. However, doing so would likely increase enrollment and, therefore, increase state Medicaid costs. SSA, in an e-mail, agreed with GAO's description of its implementation of MIPPA requirements.