oversight

Low-Income Medicare Beneficiaries: Further Outreach and Administrative Simplification Could Increase Enrollment

Published by the Government Accountability Office on 1999-04-09.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to Congressional Requesters




April 1999
                 LOW-INCOME
                 MEDICARE
                 BENEFICIARIES
                 Further Outreach and
                 Administrative
                 Simplification Could
                 Increase Enrollment




GAO/HEHS-99-61
          United States
GAO       General Accounting Office
          Washington, D.C. 20548

          Health, Education, and
          Human Services Division

          B-282061

          April 9, 1999

          The Honorable Pete Stark
          Ranking Minority Member, Subcommittee on Health
          Committee on Ways and Means
          House of Representatives

          The Honorable Jim McDermott
          House of Representatives

          Medicare provides health insurance coverage to nearly 39 million
          Americans who are elderly, disabled, or have end-stage renal disease
          (ESRD). However, the program’s cost-sharing provisions—including
          premiums, deductibles, and coinsurance—make participation in the
          program difficult to afford for low-income individuals. In 1995, the annual
          cost-sharing liability for Medicare-covered services was typically about
          $760 per beneficiary. This liability represented about 10 percent of income
          for a single person and about 15 percent of income for couples at the
          federal poverty level.1 While many Medicare beneficiaries with low
          incomes have protection from these costs through Medicaid—the
          federal-state health financing program for low-income people—those with
          low incomes who do not qualify for Medicaid face significant cost-sharing
          obligations.

          To assist low-income Medicare beneficiaries with potentially high
          out-of-pocket costs, the Congress enacted three programs: the Qualified
          Medicare Beneficiary (QMB) program; the Specified Low-Income Medicare
          Beneficiary (SLMB) program; and the Qualifying Individuals (QI) program,
          whereby state Medicaid programs help bear the beneficiary share of costs,
          which varies depending on the beneficiary’s income. However, there has
          been continuing concern about the level of enrollment in these programs.
          Therefore, you asked us to

      •   highlight the demographic and socioeconomic characteristics of
          (1) Medicare beneficiaries who enroll as a QMB or SLMB and (2) Medicare
          beneficiaries who qualify for QMB or SLMB but do not enroll,
      •   examine reasons why eligible beneficiaries are not enrolled, and
      •   identify strategies to increase enrollment.




          1
           This level is based on federal guidelines prepared by the Department of Health and Human Services.
          The federal poverty level in 1995 was $7,470 and $10,030 for couples.



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                   To perform our work, we conducted a statistical analysis of recent surveys
                   by the Health Care Financing Administration (HCFA), the Census Bureau,
                   and the Federal Reserve Board. We also interviewed officials at HCFA, the
                   Social Security Administration (SSA), Medicaid agencies in seven states,
                   and advocates for low-income elderly. We conducted our work from
                   November 1998 to March 1999 in accordance with generally accepted
                   government auditing standards. (For a detailed description of our scope
                   and methodology, see app. I.)



                   Although enrollment in QMB and SLMB has increased since the programs
Results in Brief   were implemented, many potentially eligible Medicare beneficiaries are
                   not enrolled in these programs. 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. 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. In addition to having low income, these individuals
                   tend to have health conditions affecting their capacity to perform various
                   activities. 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 have no health insurance coverage other than Medicare. Our
                   analysis also indicates that QMB and SLMB enrollment can vary by specific
                   demographic characteristics. 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. Conversely,
                   enrollment is lower for beneficiaries who are white, widowed, married, or
                   have Medicare coverage because of age rather than disability.

                   Advocates for low-income elderly and state officials we interviewed
                   attributed persistently low QMB and SLMB enrollment to limited program
                   awareness among beneficiaries and the programs’ administrative
                   complexity. Potentially eligible individuals are perceived to simply be
                   unaware of these programs, their benefits, or their eligibility criteria.
                   Moreover, limited beneficiary awareness is thought to be exacerbated by
                   cultural and language barriers as well as perceptions of social stigma
                   related to enrolling in the Medicaid-administered QMB and SLMB programs.
                   Enrollment can be further hindered by a burdensome and complex
                   application process that can require beneficiaries to interact with more
                   than one government agency. Also, low enrollment in these programs is




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             thought to result from state cost-sharing obligations that limit states’
             incentives to notify and enroll eligible individuals.

             Recently, HCFA and SSA have initiated efforts aimed at identifying strategies
             for increasing QMB and SLMB enrollment. HCFA has established a task force
             that is in the process of identifying targets for increased enrollment and
             strategies for reaching these goals. SSA selected one state, Massachusetts,
             and 11 communities in six other states to participate in a demonstration
             project to examine the effects of various approaches on enrollment.
             Further, a number of states we contacted have taken steps to simplify
             their application and enrollment processes, and advocates and state
             officials who we interviewed suggest that expanded administrative
             simplification efforts in conjunction with more creative and targeted
             outreach could increase QMB and SLMB enrollment.


             Medicare is the nation’s largest health insurance program and provides
Background   coverage for a broad array of services. However, many beneficiaries
             purchase supplemental coverage to offset the program’s cost-sharing
             provisions—that is, premiums, deductibles, and coinsurance.2 To the
             extent that beneficiaries can purchase insurance to supplement their
             Medicare coverage, they limit their potential cost-sharing liability.
             However, many low-income persons—especially those with poor
             health—are less able to afford such supplemental coverage.

             About 2.5 million persons who qualify for Medicare and are poor also
             receive assistance from Medicaid, a joint federal-state program that
             provides health care services for certain vulnerable and needy individuals
             and families with low incomes and resources.3 For those who are eligible
             for full Medicaid coverage, the Medicare health care coverage is
             supplemented by services that are available under their state’s Medicaid
             program, which may include prescription drugs and long-term care
             services—generally not available under Medicare—as well as payment of
             Medicare part B premiums. Also, Medicare makes payments for


             2
              Part A—which covers inpatient care in a hospital or skilled nursing facility, post-institutional home
             health care, and hospice care—typically has no premiums, but deductibles for an inpatient hospital
             period were $764 in 1998. Beneficiaries pay no coinsurance for the first 60 days of inpatient care, but
             they pay 25 percent of the deductible for the 61st through 90th days, and 50 percent of the deductible
             for hospitalization past the 90th day. For part B—which covers physician services, outpatient hospital
             services, non-post-institutional home health care, and other health care services—1998 premiums were
             $43.80 a month, or $526 a year. Also, beneficiaries must pay a coinsurance of 20 percent of allowable
             expenses.
             3
              In 1996, Medicaid provided medical assistance to about 36 million low-income individuals.



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    Medicare-covered services before the Medicaid program makes any
    payments.

    To assist low-income Medicare beneficiaries with potentially high
    out-of-pocket costs, the Congress established the QMB, SLMB, and QI
    programs.

•   QMB,  implemented in 1986,4 is a benefit program for Medicare beneficiaries
    with incomes at or below 100 percent of the federal poverty level. Under
    QMB, state Medicaid programs are responsible for these individuals’
    Medicare premiums, deductibles, and coinsurance.
•   SLMB, implemented in 1993,5 requires state Medicaid programs to pay
    Medicare part B premiums (but not the deductibles or coinsurance) for
    individuals with incomes above 100 percent but less than 120 percent of
    the federal poverty level.
•   QI, implemented in 1998, requires state Medicaid programs to pay all of the
    Medicare part B premiums for individuals with incomes at least 120
    percent but less than 135 percent of the federal poverty level, and to
    provide a small rebate of Medicare premiums for beneficiaries with
    incomes at least 135 percent but less than 175 percent of the federal
    poverty level. The QI program is funded with $1.5 billion in federal dollars
    over a 5-year period.6 Because the funding amount is fixed, eligible
    individuals receive assistance on a first-come, first-served basis.

    These Medicare buy-in programs and full Medicaid have varying eligibility
    criteria and benefits. (See table 1.)




    4
     QMB was enacted as an optional benefit through the Omnibus Budget Reconciliation Act (OBRA) of
    1986. The Medicare Catastrophic Coverage Act of 1988 made the QMB benefit mandatory, effective
    January 1, 1989.
    5
     SLMB was enacted under OBRA 1990, effective January 1, 1993.
    6
     Because the QI program did not become effective until 1998, we did not examine enrollment in this
    program.



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                                         B-282061




Table 1: Medicaid Eligibility Criteria
and Benefits for Medicare                                                                                                  Enrollment as of
Beneficiaries Under Full Medicaid,       Program           Eligibility criteria               Benefits                     December 1998a
QMB, SLMB, and QI                        Full              Low-income Medicare                Medicare part B                    2,450,000
                                         Medicaid          beneficiaries as defined by        premiums paid by the
                                                           each state                         state Medicaid program
                                                                                              and Medicaid services,
                                                                                              including those covered
                                                                                              under Medicare
                                         QMB               Medicare beneficiaries             Medicare premiums,                 2,420,000
                                                           whose (1) incomes are at or        deductibles, and
                                                           below 100 percent of the           coinsurance paid by the
                                                           federal poverty level and (2)      state Medicaid programc
                                                           assets are no greater than
                                                           twice the limit for
                                                           Supplemental Security
                                                           Income (SSI)b
                                         SLMB              Medicare beneficiaries with Medicare part B                             290,000
                                                           (1) incomes above 100        premiums paid by the
                                                           percent but less than 120    state Medicaid programc
                                                           percent of the federal
                                                           poverty level and (2) assets
                                                           no greater than twice the
                                                           limit for SSIb
                                         QI                Medicare beneficiaries who         Medicare part B                       16,000
                                                           are otherwise ineligible for       premiums paid for
                                                           Medicaid with (1) incomes          income 120 percent to
                                                           at least 120 percent but           less than 135 percent of
                                                           less than 175 percent of the       the federal poverty level
                                                           federal poverty level and (2)      in 1999; a $2.23
                                                           assets no greater than twice       premium contribution for
                                                           the limit for SSIb                 income 135 percent to
                                                                                              less than 175 percent of
                                                                                              the federal poverty level
                                         a
                                         Based on administrative data provided by HCFA.
                                         b
                                             The asset limits for SSI are $2,000 for individuals and $3,000 for couples.
                                         c
                                         Individuals may also be eligible for Medicaid services.




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                        Enrollment in QMB has increased steadily since it was implemented.7
Program Enrollment      However, nearly half of all Medicare beneficiaries who are eligible for the
Has Increased, but      QMB and SLMB programs are not enrolled. Moreover, these beneficiaries are

Some of the Most        some of the most vulnerable among the Medicare population.

Vulnerable Eligible
Medicare
Beneficiaries Are Not
Enrolled
QMB Enrollment Has      HCFA  administrative records based on state-reported enrollment data
Increased               indicate that enrollment in QMB increased from over 760,000 in 1991 to over
                        2.4 million in 19988 (see fig. 1). Following steady enrollment growth from
                        1991 to 1994, enrollment has largely stabilized. While enrollment appears
                        to increase sharply between 1994 and 1995, this increase largely represents
                        a change in states’ reporting methods, which had undercounted QMB
                        enrollees.9




                        7
                         Trend data on SLMB were not available.
                        8
                         Based on part B enrollment data. Most beneficiaries have both part A and part B Medicare coverage.
                        9
                         QMB enrollment was underreported prior to 1995 because some QMBs were counted as full Medicaid
                        recipients. This was changed beginning in 1995, explaining much of the apparent growth in QMB
                        enrollment between 1994 and 1995.



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Figure 1: Growth in QMB Part B
Enrollment From 1991 to 1998     3.0   Part B QMBs (Millions)



                                 2.5



                                 2.0



                                 1.5



                                 1.0



                                 0.5



                                  0

                                   1991          1992           1993       1994          1995          1996         1997             1998




                                 Note: In 1995, states changed their reporting method, resulting in the apparent sharp increase in
                                 reported enrollment.




Many QMB- and                    While QMB enrollment has increased gradually over time, a relatively low
SLMB-Eligible Medicare           percentage of Medicare beneficiaries who are eligible for the QMB and SLMB
Beneficiaries Are Not            programs actually enroll. Based on our analysis of the 1996 Medicare
                                 Current Beneficiary Survey (MCBS), an estimated 8.6 million Medicare
Enrolled                         beneficiaries had income levels low enough to qualify them for these
                                 programs. Within this group, about 61 percent had assets within the QMB
                                 and SLMB thresholds, based on data from the Survey of Consumer Finance
                                 (SCF). Considering both income and assets, we estimate that about
                                 5.1 million Medicare beneficiaries are potentially eligible for the QMB or
                                 SLMB program, with MCBS reporting about 2.9 million individuals enrolled in
                                 QMB or SLMB. Therefore, about 2.2 million—or 43 percent—of the estimated
                                 eligible population are not enrolled. Other analysts have examined
                                 enrollment for QMB and enrollment for SLMB separately and found that
                                 enrollment is higher in the QMB program but lower in the SLMB program,
                                 which serves a population with incomes slightly higher than the QMB
                                 population and with more limited benefits.




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Demographic Profiles of     Based on our analysis of MCBS, the general profile of individuals who are
Enrolled and Nonenrolled    eligible but do not enroll in QMB and SLMB is similar to that of program
Eligibles Are Similar       enrollees.10 The characteristics of these two groups place them among the
                            most vulnerable Medicare beneficiaries. In addition to having a lower
                            income than noneligible Medicare beneficiaries, QMB and SLMB eligibles and
                            enrollees have fewer years of education and health conditions that limit
                            their capacity to perform various activities. A relatively high percentage of
                            both the QMB and SLMB eligible and enrolled are female, single, living alone,
                            or a member of a minority group.

                            While the general profiles of enrolled and nonenrolled QMB- and
                            SLMB-eligible individuals are similar, certain characteristics distinguish
                            them. For example, QMB and SLMB enrollees are more likely to be disabled
                            or reside in a facility than those who are eligible but not enrolled. In
                            contrast, individuals who are eligible but not enrolled are more likely to
                            not have health insurance coverage other than Medicare or be 80 years of
                            age or older.


Enrollment Is Highest for   Our analysis indicates that enrollment was higher among some of the most
Those Who Are Most          vulnerable beneficiaries—those in poor health; receiving Medicare
Vulnerable                  coverage because of a disability or ESRD; with difficulty performing certain
                            life activities; or residing in facilities, such as a nursing home, assisted
                            living facility, or mental health facility. Enrollment was also higher among
                            individuals having 8 or fewer years of education. Conversely, enrollment
                            was lower among beneficiaries who had 13 or more years of education,
                            were in better health, had Medicare coverage due to age, or were living in
                            the community.

                            QMB and SLMB enrollment was also associated with beneficiaries’ race and
                            marital status. For example, Asian- and African-Americans were more
                            likely to be enrolled than whites. Also, beneficiaries who were separated
                            or never married were more likely to be enrolled than those who were
                            widowed or married. (See app. II for more detailed information on the
                            characteristics of QMB and SLMB enrollees, individuals who are eligible but
                            not enrolled, and other Medicare beneficiaries.)




                            10
                             For our analysis, we examined the characteristics of individuals who are eligible for QMB or SLMB
                            based upon income alone.



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                               The state officials and advocates for low-income elderly who we
Low QMB and SLMB               interviewed indicated that low QMB and SLMB enrollment persists because
Enrollment Attributed          of limited program awareness among beneficiaries and the administrative
to Limited Program             complexity associated with the programs. Beneficiaries are perceived to
                               have insufficient knowledge of the programs, their benefits, and their
Awareness and                  eligibility criteria—a problem exacerbated by cultural and language
Administrative                 barriers and perceptions of social stigma related to enrolling in
                               Medicaid-administered programs. Furthermore, establishing QMB and SLMB
Complexity                     eligibility can be a complex process. For potential beneficiaries, lengthy
                               applications and eligibility verification requirements can discourage them
                               from seeking enrollment. For agencies, the division of financial and
                               programmatic responsibilities between the federal government and states
                               can provide a disincentive to assume full responsibility for maximizing
                               enrollment.


Insufficient and Ineffective   Although the QMB and SLMB programs have been operable for a number of
Outreach Limits Program        years, most of those we interviewed reported that many potential
Awareness                      recipients do not enroll because they do not know the programs existed.
                               Misperceptions about the programs are also thought to deter some
                               beneficiaries from enrolling. For example, an individual who meets the
                               eligibility criteria might not apply because of a belief that the program is
                               intended only for “poor people.” Some potential beneficiaries are thought
                               not to apply because of their apprehensions or misperceptions about their
                               state’s Medicaid estate recovery practices. These individuals may fear that,
                               following their death, their state will attempt to recover QMB and SLMB
                               payments made on their behalf through liens on their estate and jeopardize
                               the financial well-being of a surviving spouse or their children. Other
                               potential beneficiaries think the programs are a form of welfare and are
                               unwilling to accept this type of assistance.

                               Some states we interviewed attributed limited program awareness, in part,
                               to either a general lack of outreach efforts or the lack of effective
                               outreach. They believe, for example, that current outreach efforts are
                               insufficient or ineffective in raising the level of program awareness among
                               beneficiaries with limited English language skills or in allaying concerns
                               regarding the acceptance of public assistance. Our analysis of MCBS data
                               similarly suggests that current outreach efforts may not be reaching all
                               populations. QMB and SLMB enrollment is comparatively high for
                               beneficiaries who are ill or disabled or reside in facilities such as those
                               that provide long-term care. Even without outreach, however, these
                               individuals are more apt to become enrolled because their health



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                            conditions increase their number of encounters with the medical
                            community—some even reside in medical settings—and their caregivers
                            have financial incentives to ensure that they are covered. In contrast, QMB
                            and SLMB enrollment is lower among beneficiaries who are aged, better
                            educated, in better health and with less need for medical care, or living
                            independently in the community—groups for whom outreach efforts are
                            more necessary for increasing program awareness or addressing concerns
                            or misperceptions.

                            Through our interviews with states, we also found that most discussed
                            previous or ongoing outreach efforts. Only one state reported new
                            outreach initiatives for increasing QMB and SLMB enrollment, and one state
                            reported targeting its outreach to specific groups.


Administrative Complexity   Even with improved outreach, boosting enrollment in QMB and SLMB may
Impedes QMB and SLMB        be undermined by the administrative complexity associated with
Enrollment                  determining eligibility. The application process is cumbersome and
                            lengthy, and other administrative processes must be coordinated among
                            various federal and state government agencies, given that Medicare is
                            administered by the federal government and Medicaid is administered by
                            the states.

                            According to the state officials and advocates we interviewed, the process
                            for applying for QMB and SLMB benefits could be a key factor limiting
                            enrollment. In some states, applicants are required to complete the full
                            Medicaid application, which can exceed 10 pages and be difficult to read,
                            given its small print. In addition, applicants may require the assistance of a
                            state caseworker to complete the application. Some states require
                            information that will allow the verification of an applicant’s reported
                            resources—a process that can be onerous and time-consuming to both
                            applicants and state workers. Further, some states require applicants to
                            have a face-to-face interview at either a social service or an aging office,
                            instead of accepting applications over the phone, as other states do.
                            Requiring face-to-face interviews likely impedes enrollment for those who
                            are homebound or concerned about perceived welfare stigma.

                            Other administrative processes—typically those that require coordination
                            among state and federal agencies—can result in eligible individuals’
                            enrollment being delayed. For example, state Medicaid programs may
                            need to coordinate with HCFA and SSA to verify information such as




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                         enrollment in Medicare and income from Social Security, creating the
                         potential for administrative delays and errors.

                         Some advocates have also suggested that the financing of the QMB and SLMB
                         programs, with state cost-sharing responsibilities, has deterred states from
                         embracing the programs and created a disincentive for states to conduct
                         additional outreach or simplify the application process. A February 1998
                         National Governors’ Association (NGA) position on the financing
                         arrangement supports this belief. NGA stated that it “cannot support
                         Medicare reform strategies, such as increased cost-sharing obligations for
                         the dually eligible, that result in cost shifts to the states.”11 NGA further
                         stated that Medicare, as a federal program, should bear all of its costs, but
                         if it were to continue to make Medicaid responsible for meeting the
                         Medicare cost-sharing obligations of low-income beneficiaries, “Congress
                         should at a minimum clarify that copayments may be reimbursed at
                         Medicaid rather than Medicare rates.”12


                         The federal government has developed various strategies to boost
Enhanced Outreach        enrollment in QMB and SLMB. A number of these strategies focus on
and Simplified           enhancing outreach to increase program awareness and simplifying the
Enrollment Could         enrollment process. For example, as part of its Government Performance
                         and Results Act (GPRA) goals, HCFA has convened a task force to develop an
Increase Participation   outreach, enrollment, and eligibility simplification strategy for increasing
in QMB and SLMB          enrollment of those who are dually eligible. SSA is conducting a pilot
                         project intended to increase referral of potential beneficiaries to state
                         Medicaid programs.

                         The state officials and advocates we interviewed recommended that
                         outreach be improved through strategies such as increasing overall
                         outreach efforts; targeting groups that include large numbers of eligible
                         but nonenrolled individuals; and developing partnerships with key
                         stakeholders, such as seniors’ advocates, area agencies on aging, and other
                         community-based organizations. They also recommended strategies for
                         streamlining the application process and providing flexibility in applying
                         eligibility rules to make it easier for eligible individuals to become enrolled
                         in the programs.

                         11
                           National Governors’ Association, Policy Positions (Washington, D.C., Feb. 1998).
                         12
                           Since Medicaid reimbursement rates tend to be lower than Medicare rates, such a change would
                         result in cost savings to states. Section 4714 of the Balanced Budget Act of 1997 (P.L. 105-33) clarified
                         that states were not required to provide payments for deductibles, coinsurance, or copayments for the
                         full Medicare cost-sharing amount made under the state plan for services provided to individuals other
                         than Medicare beneficiaries.



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HCFA Initiatives to           Since the programs were developed, HCFA has made several efforts to
Increase Enrollment           increase enrollment in QMB and SLMB. Promotional efforts have included
                              mailing notices to prospective enrollees, distributing pamphlets on the
                              programs, advertising in the media, and developing a section on QMB and
                              SLMB in its Medicare handbook for beneficiaries. HCFA has also issued
                              directives and letters to states providing guidance on program
                              administration and simplification. For example, in October 1998, HCFA
                              wrote state Medicaid program directors suggesting that they develop
                              outreach and enrollment strategies modeled on those used for the new
                              State Children’s Health Insurance Program (SCHIP)—a strategy some
                              advocates strongly support.

                              In response to the Social Security Amendments of 1994, HCFA established a
                              list of newly eligible Medicare beneficiaries that includes demographic
                              information, such as income from Social Security, which states can use to
                              identify individuals potentially eligible for QMB and SLMB benefits.13
                              Currently, HCFA is seeking to improve QMB and SLMB enrollment through
                              one of its GPRA goals. To reach this goal, HCFA plans to

                          •   establish targets for increased QMB and SLMB enrollment;
                          •   develop an outreach, enrollment, and eligibility simplification strategy;
                          •   identify best practices in collaboration with states; and
                          •   measure progress toward meeting these goals.

                              HCFA intends to recommend targets and best practices in summer 1999 and
                              begin measuring progress toward these goals in fiscal year 2000.


SSA Efforts to Increase       SSA is an important point of contact for those potentially eligible for QMB
Enrollment                    and SLMB, not only because it is responsible for enrolling new Medicare
                              beneficiaries but because Social Security is a primary source of income for
                              many low-income beneficiaries. However, a majority of individuals file for
                              Social Security benefits before age 65—when most become eligible for
                              Medicare—and do not have ongoing contact with SSA.14 SSA’s efforts to
                              notify potentially eligible individuals include sending program information
                              in cost-of-living adjustment notices to all Social Security recipients and
                              providing QMB and SLMB information and referral as part of the agency’s

                              13
                                Section 154 of the Social Security Amendments of 1994 (P.L. 103-432) directs the Secretary of Health
                              and Human Services to implement a method for obtaining information from newly eligible Medicare
                              beneficiaries that could be used to determine their QMB eligibility and to transmit this information to
                              the state in which the beneficiary resides.
                              14
                               When these individuals become eligible for Medicare, they are automatically enrolled in part A and
                              part B and, therefore, do not have to contact SSA again to enroll in Medicare.



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                               in-person contacts and toll-free telephone service. SSA has also included
                               information about the QMB and SLMB programs in pamphlets available at
                               Social Security offices and distributed to interested individuals.

                               SSA is currently conducting a demonstration project with selected states to
                               evaluate which strategies are most effective in increasing the number of
                               SSA referrals of potentially eligible beneficiaries to state agencies. The
                               demonstration project will be conducted in Massachusetts and 11
                               communities in six other states, which were selected based on each
                               participating state’s offer to provide access to a concentration of elderly,
                               disabled, and low-income individuals. Under this project, SSA is testing four
                               approaches. In one approach, SSA will use its death report process to
                               identify potential buy-in eligibles and refer them to the state’s Medicaid
                               office to file an application for benefits. In the other three approaches, SSA
                               will identify and send mailings to potentially eligible individuals in the
                               selected communities. Respondents will be screened by SSA employees
                               and then referred to complete an application (1) with an SSA employee;
                               (2) with a state Medicaid official located in the SSA office; or (3) with an
                               official at the state Medicaid office, typically at another location. Final
                               eligibility determinations are still performed by the state Medicaid agency,
                               regardless of the approach. The demonstration is scheduled to continue
                               through the end of 1999, and an evaluation of the project and findings on
                               the relative effectiveness of the referral methods is expected to be
                               released in spring 2000.


Increased and More             In addition to HCFA’s and SSA’s recent initiatives to increase QMB and SLMB
Effective Outreach Could       enrollment, the state officials and advocates we interviewed
Increase Enrollment            recommended a number of strategies, some of which have been used, for
                               intensifying and broadening the range and scope of outreach efforts.

                           •   Target outreach to populations with particularly low enrollment:
                               individuals who are widowed, aged 65 or older, white, have 13 years or
                               more of education, or report good health status.
                           •   Target low-income Medicare beneficiaries with health conditions and high
                               use of health care services, who are most likely to benefit from
                               supplemental coverage of Medicare coinsurance and deductibles. For
                               example, Medicare benefits statements, which show Medicare’s payments
                               and the beneficiary share of the cost, could include a brief notice
                               suggesting that low-income beneficiaries apply for QMB.
                           •   Use other methods and sources to provide information on QMB and SLMB.
                               For example, states could coordinate with local utility companies to



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                                  include QMB and SLMB literature with mailings to subscribers. Delaware’s
                                  Division of Health and Social Services attempts one-on-one outreach at
                                  senior picnics, health fairs, and senior centers. In Arizona, a state coalition
                                  enrolled volunteers to conduct door-to-door outreach. In addition, for the
                                  SCHIP program, HCFA recommends that states allow application at a wide
                                  variety of sites, including public schools and school-based health clinics.
                              •   Enlist physicians and other health care professionals in outreach efforts,
                                  such as encouraging them to advise their low-income patients to apply for
                                  QMB.
                              •   Coordinate outreach with other programs providing assistance to
                                  low-income individuals. For example, elderly pharmacy assistance
                                  programs can help identify individuals with ongoing prescription drug
                                  needs, who are potentially eligible for QMB and SLMB.
                              •   Establish partnerships with local stakeholders to increase QMB and SLMB
                                  enrollment. For example, Tennessee and Arizona partnered with
                                  organizations such as religious organizations, advocacy groups, state and
                                  local agencies, voluntary health agencies, health professionals and
                                  providers, area agencies on aging, and other seniors groups to develop
                                  task forces to work on outreach, training, and enrollment.
                              •   Provide outreach information and applications in languages other than
                                  English.

                                  While improved outreach could improve enrollment, many of the proposed
                                  strategies would likely require the commitment of additional resources by
                                  states and HCFA.


Simplifying the Application       State officials and advocates also suggested that additional efforts are
Process and Eligibility           needed to simplify the application process and eligibility rules. Some
Rules Could Also Increase         approaches that they recommended include the following:
Enrollment                    •   Use a shorter application form. For example, some states have developed
                                  a one- or two-page application for QMB and SLMB.
                              •   Allow beneficiaries to declare the eligibility information they provide as
                                  true and accurate. For example, Delaware allows a self-declaration that
                                  the applicant meets the asset requirements for enrollment in QMB and SLMB,
                                  rather than requiring documentation to verify assets.
                              •   Eliminate the need for applicants to come in person to Medicaid or other
                                  state agency offices to apply. Some states have computerized portions of
                                  the eligibility determination, which could allow the testing of an electronic
                                  application. Intermediaries such as area agencies on aging and
                                  community-based organizations could assist in preparing and transmitting



                                  Page 14                          GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
                   B-282061




                   applications electronically to state Medicaid offices. Arizona offers help
                   filling out applications via telephone. New York is encouraging local
                   counties to experiment with allowing those who are potentially eligible to
                   enroll through area agencies on aging staffed with state intake workers.
                   Also, Tennessee performed a 3-month screening of potential beneficiaries
                   at the U.S. Department of Agriculture’s commodity distribution centers.15
               •   Relax program eligibility rules. For example, Arizona excludes items such
                   as household goods and personal effects, mineral and timber rights, burial
                   and life insurance from countable resources. Furthermore, most states
                   have no asset requirements for SCHIP applicants.
               •   Share automated data to improve enrollment.
               •   Expand the use of retroactive eligibility so beneficiaries can be
                   compensated for medical expenses incurred while their application is
                   pending. QMB and SLMB applications and eligibility determination can take 1
                   month or longer before enrollment is completed. Potentially eligible
                   individuals who have recently incurred medical expenses covered under
                   QMB, therefore, may be more likely to complete the application process if
                   they expect to be reimbursed for these expenses.

                   For states that use a uniform application to establish eligibility for multiple
                   programs, developing a simpler application specifically for QMB and SLMB
                   may also have some drawbacks. While a simpler application may help
                   improve QMB and SLMB enrollment, it would make it more difficult to
                   determine whether the applicant is also eligible for other or more
                   comprehensive programs for low-income individuals. For example, some
                   states that maintain longer application forms and require verification of
                   assets use the information to screen the individual for full Medicaid
                   benefits and other programs such as low-income housing or energy
                   assistance. In certain circumstances, a streamlined QMB or SLMB application
                   could hinder a state agency’s ability to identify applicants who would also
                   qualify for more comprehensive assistance or benefits.


                   As proposals to restructure and increase the long-term financial strength
Concluding         of the Medicare program are considered in the Congress, increased
Observations       attention may be focused on the best approaches for providing financial
                   assistance to low-income Medicare beneficiaries. The persistence of
                   relatively low enrollment in the QMB and SLMB programs suggests that
                   enhanced outreach or simplified enrollment processes would be helpful in
                   reaching a larger share of eligible low-income Medicare beneficiaries.

                   15
                    The Food and Nutrition Service, an agency of the U.S. Department of Agriculture, makes food
                   available through various programs, including the Emergency Food Assistance Program, the
                   Commodity Supplemental Food Program, and Nutrition Program for the Elderly.



                   Page 15                                   GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
                  B-282061




                  Effective targeted outreach can also serve as a means to optimize limited
                  outreach resources. Assessment of ongoing efforts—including SSA’s
                  demonstration project, SCHIP outreach and enrollment efforts by states,
                  and HCFA’s GPRA efforts—could yield new strategies to increase QMB and
                  SLMB enrollment. Successful approaches from these efforts could then be
                  widely disseminated to enhance outreach and enrollment.


                  We obtained comments on a draft of our report from HCFA and SSA. HCFA
Agency Comments   generally agreed with the strategies for increasing enrollment in the QMB
                  and SLMB programs suggested by the advocates and state officials we
                  interviewed. HCFA also indicated its commitment to providing more
                  effective outreach and removing administrative barriers to enrollment and
                  highlighted its current efforts under GPRA to increase QMB and SLMB
                  enrollment.

                  HCFA  also noted that our estimate of the population potentially eligible for
                  the QMB and SLMB programs is lower than their forthcoming estimate.
                  Estimating the number of individuals eligible for means-tested programs is
                  challenging because most available surveys have shortcomings of one kind
                  or another. For this reason, we recognize that different methods can
                  legitimately produce different estimates of this population. Further, as
                  estimates of this population are produced from surveys that are based on
                  statistical samples, these estimates are subject to sampling error so that
                  the actual level of enrollment is likely to be higher or lower than the point
                  estimate. In our opinion, the differences among the various estimates of
                  this population narrow when these sampling errors are taken into account.

                  HCFA and SSA also noted that other researchers have found significantly
                  higher enrollment among QMB-eligible individuals than SLMB-eligible
                  individuals. In addition, HCFA indicated that combining these groups could
                  mask their differences. We acknowledge in our report that other research
                  has determined that the QMB program reaches a larger portion of eligible
                  individuals than does the SLMB program. We also acknowledge that
                  demographic differences could potentially exist in (1) the enrolled QMB
                  and SLMB populations and (2) the nonenrolled eligible QMB and SLMB
                  populations. However, our study’s objective was not to distinguish
                  between these groups, but rather to compare the enrolled and the
                  nonenrolled eligible populations for both programs. Moreover, MCBS
                  income data do not permit differentiating nonenrolled QMB and SLMB
                  eligibles, and given the small number of SLMB enrolled and nonenrolled
                  eligibles included in the MCBS sample, discrete estimates about their



                  Page 16                         GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
B-282061




characteristics would not likely be reliable. Nonetheless, this should not
be a significant limitation to our study’s objective because, based on the
eligibility criteria for these programs for the time period we examined,
only about $2,000 in income separated an individual eligible for QMB from
one eligible for SLMB.

Both HCFA and SSA suggested technical clarifications, which we included
where appropriate. HCFA’s written comments are provided as appendix III.


As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this letter until 30 days after its
issue date. At that time, we will send copies to other interested
congressional committees and members and agency officials. We will also
make copies available to others upon request.

Please call me at (202) 512-7114 if you have any questions about the
information provided in this report. The information presented in this
report was developed by N. Rotimi Adebonojo, Senior Evaluator; Wayne
Turowski, Computer Specialist; and Mark Vinkenes, Senior Social Science
Analyst, under the direction of John Dicken, Assistant Director.

Sincerely yours,




Kathryn G. Allen
Associate Director, Health Financing
  and Public Health Issues




Page 17                           GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Contents



Letter                                                                                                1


Appendix I                                                                                           20

Scope and
Methodology
Appendix II                                                                                          23

Medicare Beneficiary
Profiles
Appendix III                                                                                         27

Comments From the
Health Care Financing
Administration
Tables                  Table 1: Medicaid Eligibility Criteria and Benefits for Medicare              5
                          Beneficiaries Under Full Medicaid, QMB, SLMB, and QI
                        Table I.1: QMB and SLMB Asset and Income Thresholds,                         21
                          Individuals 65 Years or Older, 1995
                        Table: II.1: Percentage of QMB and SLMB Enrollees, Eligible but              23
                          Nonenrolled QMBs and SLMBs, and Beneficiaries Ineligible for
                          QMB or SLMB by Demographic and Other Characteristics
                        Table II.2: Percentage of Individuals Potentially Eligible for QMB           24
                          or SLMB Who Are Enrolled, by Demographic Characteristics
                        Table II.3: Percentage of Individuals Potentially Eligible for QMB           25
                          or SLMB Who Are Enrolled, by Health Characteristics

Figure                  Figure 1: Growth in QMB Part B Enrollment From 1991 to 1998                   7




                        Page 18                         GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Contents




Abbreviations

CPS        Current Population Survey
ESRD       end-stage renal disease
GPRA       Government Performance and Results Act
HCFA       Health Care Financing Administration
MCBS       Medicare Current Beneficiary Survey
NGA        National Governors’ Association
OBRA       Omnibus Budget Reconciliation Act
QI         Qualifying Individuals
QMB        Qualified Medicare Beneficiary
SCF        Survey of Consumer Finances
SCHIP      State Children’s Health Insurance Program
SLMB       Specified Low-Income Medicare Beneficiary
SSA        Social Security Administration
SSI        Supplemental Security Income


Page 19                       GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Appendix I

Scope and Methodology


             We conducted an analysis of the 1996 Medicare Current Beneficiary
             Survey (MCBS) on access to care to estimate the number and
             characteristics of Medicare beneficiaries who enroll as a QMB or SLMB as
             well as those who may qualify but do not enroll. Given certain limitations
             of MCBS, we used the March 1996 Current Population Survey (CPS) and the
             1995 Survey of Consumer Finances (SCF) to further refine our estimates.
             To examine reasons why eligible beneficiaries do not enroll and identify
             strategies to increase enrollment, we reviewed the available literature and
             interviewed representatives from HCFA, which administers Medicare and
             Medicaid; SSA, which is responsible for enrolling eligible individuals in
             Medicare; national organizations that represent elderly and low-income
             persons; state health insurance counseling agencies; and Medicaid
             agencies in Arizona, California, Delaware, Michigan, Nebraska, New York,
             and Tennessee. We excluded the Qualifying Individuals program from our
             review due to its recent enactment.

             We used MCBS to conduct our analysis because it (1) contains
             comprehensive information on Medicare beneficiaries, including their
             demographic characteristics, health status, and health care use, and
             (2) relies on HCFA administrative records rather than self-reported
             information for QMB and SLMB enrollment status. This latter factor is
             important because previous research suggests that QMB enrollees and
             individuals who are eligible but not enrolled in the program are not always
             aware of their enrollment status, which could affect the reliability of our
             estimates. Because MCBS does not contain information on assets and only
             provides income information in ranges, we also analyzed the 1995 SCF to
             obtain additional asset information and the 1996 CPS March Supplement to
             obtain additional income information.

             Using MCBS, we categorized Medicare beneficiaries as (1) enrolled in QMB
             or SLMB, (2) eligible for QMB or SLMB but not enrolled, and (3) ineligible for
             QMB or SLMB. The first group includes any individual enrolled in QMB or SLMB
             for at least 1 month. The second group consisted of beneficiaries with
             income less than or equal to $10,000, no QMB or SLMB enrollment, and less
             than continuous coverage by full Medicaid. The third group consists of any
             Medicare beneficiary with income greater than $10,000 and no QMB, SLMB,
             or Medicaid enrollment.

             For purposes of our analysis, we did not distinguish between QMB and SLMB
             enrollees. Likewise, individuals who were potentially eligible for QMB were
             not distinguished from those who were eligible for SLMB. This is because
             the numbers of enrolled and potentially eligible SLMB populations are



             Page 20                          GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
                                    Appendix I
                                    Scope and Methodology




                                    relatively small and the resulting sampling errors would have been too
                                    great to allow meaningful comparisons. Also, because MCBS measures
                                    income within a range rather than as a specific amount, the survey
                                    precludes distinguishing individuals who are potentially eligible for QMB
                                    from those who are eligible for SLMB.

                                    As shown in table I.1, the maximum income that an individual could have
                                    to meet the SLMB income threshold of 120 percent of the federal poverty
                                    level was $8,964; for a couple, this income threshold was $12,036. Thus,
                                    some individuals we classified as eligible for QMB or SLMB based on the
                                    MCBS income range of less than or equal to $10,000 may have exceeded the
                                    actual income threshold for individuals. Similarly, some individuals we
                                    classified as not eligible for QMB or SLMB may have met the income
                                    thresholds for couples.

Table I.1: QMB and SLMB Asset and
Income Thresholds, Individuals 65                                  Assets                       Income per year
Years or Older, 1995                Category                Individual          Couple        Individual          Couple
                                    QMB                        $4,000            $6,000          $7,470           $10,030
                                    SLMB                        4,000             6,000            8,964           12,036

                                    To determine the extent to which the discrepancy in MCBS’ income data
                                    and the actual income requirements of the program influenced our
                                    estimates of the eligible but nonenrolled population, we conducted an
                                    analysis of income among Medicare beneficiaries using the 1996 CPS.
                                    Based on this analysis, using the SLMB income threshold of 120 percent of
                                    the federal poverty level instead of $10,000, we estimate 217,000 fewer
                                    Medicare beneficiaries could qualify for SLMB based on income. Therefore,
                                    our MCBS analysis, based on a $10,000 income threshold, slightly
                                    overestimates the number of individuals potentially eligible for QMB or
                                    SLMB.


                                    Because MCBS also does not include information on assets available to
                                    Medicare beneficiaries, we analyzed the 1995 SCF. As shown in table I.1, in
                                    general, individuals qualifying for QMB or SLMB may not have assets
                                    exceeding $4,000 in value ($6,000 for a couple). While rules for
                                    determining assets for QMB or SLMB eligibility are applied differently by
                                    state, we generally used SSI eligibility definitions for the purpose of
                                    establishing countable resources for QMB or SLMB eligibility. For example,
                                    we excluded from countable assets the value of an individual’s home and
                                    the first $1,500 in cash surrender value of life insurance policies. Using SCF,
                                    we estimate that approximately 39 percent of Medicare beneficiaries with



                                    Page 21                              GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Appendix I
Scope and Methodology




income of $10,000 or less had countable assets above the QMB and SLMB
eligibility thresholds. Thus, we deflated our MCBS estimate of the number
of eligible individuals based on income by 39 percent—our estimate, based
on SCF, of those who would not meet the QMB and SLMB asset requirements.




Page 22                        GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Appendix II

Medicare Beneficiary Profiles


Table: II.1: Percentage of QMB and
SLMB Enrollees, Eligible but                                                                                          Medicare
Nonenrolled QMBs and SLMBs, and                                                              QMB or SLMB              enrollees
Beneficiaries Ineligible for QMB or                                    QMB or SLMB             eligible but ineligible for QMB
SLMB by Demographic and Other                                              enrolled           nonenrolled              or SLMB
Characteristics                       Age
                                      Less than 65 years old                       32.2%               15.8%                6.9%
                                      65 to 79 years old                           41.7                51.9               73.5
                                      80 years old or older                        26.1                32.2               19.6
                                      Education
                                      8 years or less                              41.9                35.3               13.9
                                      9 to 12 years                                41.3                50.6               49.5
                                      13 or more years                               8.1               11.7               36.2
                                      Other demographic characteristics
                                      Member of a minority
                                      group                                        30.0                18.6                 7.5
                                      Hispanic ancestry                            13.3                11.5                 3.5
                                      Female                                       65.2                68.1               50.7
                                      Single                                       81.8                78.7               33.0
                                      Live alone                                   44.3                48.5               24.5
                                      Live in a facility                           20.7                 4.6                 0.9
                                      Basis for Medicare
                                      Aged                                         67.7                84.2               93.1
                                      Disabled                                     31.9                15.6                 6.7
                                      ESRD                                           0.4                0.3                 0.2
                                      Insurance status
                                      Medicare only                                  9.3               35.4               16.6
                                      Medicare and private
                                      insurance                                      2.9               45.7               79.2
                                      Health status
                                      Fair or poor                                 49.4                34.6               21.2
                                      Limits most or all social life               23.7                20.2               11.3
                                      Physical difficulties
                                      Seeing                                       14.1                13.0                 6.5
                                      Hearing                                        9.4                8.9                 6.1
                                      Stooping or kneeling                         47.6                38.6               24.9
                                      Lifting 10 pounds                            37.4                25.9               13.3
                                      Reaching over head                           15.4                13.8                 6.9
                                      Writing                                      13.2                 9.3                 4.8
                                      Walking two blocks                           46.1                33.8               19.7
                                      Source: GAO analysis of the 1996 MCBS.




                                      Page 23                                  GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
                                        Appendix II
                                        Medicare Beneficiary Profiles




Table II.2: Percentage of Individuals
Potentially Eligible for QMB or SLMB                                                                                 Percentage
Who Are Enrolled, by Demographic        Demographic characteristic                                                      enrolled
Characteristics                         Age
                                        Less than 65 years old                                                              50.6%
                                        65 years old or older                                                               28.9
                                        Education
                                        8 years or less                                                                     37.5
                                        9 to 12 years                                                                       29.1
                                        13 or more years                                                                    25.9
                                        Race
                                        American Indian                                                                     40.9
                                        Asian/Pacific Islander                                                              67.2
                                        African American                                                                    43.6
                                        Caucasian                                                                           30.2
                                        Other                                                                               38.4
                                        Marital status
                                        Married                                                                             30.2
                                        Widowed                                                                             27.6
                                        Divorced                                                                            37.4
                                        Separated                                                                           43.7
                                        Never married                                                                       52.9
                                        Residence
                                        Community (independent)                                                             29.6
                                        Facility                                                                            69.2
                                        Basis for Medicare
                                        Aged                                                                                28.8
                                        Aged With ESRD                                                                      74.1
                                        Disabled                                                                            50.7
                                        Disabled With ESRD                                                                  58.5
                                        ESRD                                                                                39.8
                                        Source: GAO analysis of the 1996 MCBS.




                                        Page 24                                  GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
                                        Appendix II
                                        Medicare Beneficiary Profiles




Table II.3: Percentage of Individuals
Potentially Eligible for QMB or SLMB                                                                             Percentage
Who Are Enrolled, by Health             Health characteristic                                                       enrolled
Characteristics                         Health status
                                        Excellent                                                                       23.8
                                        Very good                                                                       22.2
                                        Good                                                                            32.6
                                        Fair                                                                            41.1
                                        Poor                                                                            43.4
                                        Health limits social life
                                        No                                                                              28.7
                                        Some                                                                            41.6
                                        Most                                                                            36.4
                                        All                                                                             38.2
                                        Have difficulty stooping/kneeling
                                        No                                                                              30.2
                                        Little                                                                          27.0
                                        Some                                                                            33.3
                                        A lot                                                                           33.6
                                        Unable                                                                          43.4
                                        Have difficulty lifting 10 pounds
                                        No                                                                              27.6
                                        Little                                                                          32.6
                                        Some                                                                            35.0
                                        A lot                                                                           35.9
                                        Unable                                                                          45.8
                                        Have difficulty reaching over head
                                        No                                                                              30.4
                                        Little                                                                          38.4
                                        Some                                                                            40.9
                                        A lot                                                                           32.3
                                        Unable                                                                          40.9
                                        Have difficulty writing
                                        No                                                                              30.2
                                        Little                                                                          34.6
                                        Some                                                                            43.5
                                        A lot                                                                           39.2
                                        Unable                                                                          49.0
                                        Have difficulty walking two to three blocks
                                        No                                                                              27.2
                                                                                                                  (continued)


                                        Page 25                              GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Appendix II
Medicare Beneficiary Profiles




                                                                             Percentage
Health characteristic                                                           enrolled
Little                                                                              32.2
Some                                                                                33.5
A lot                                                                               38.8
Unable                                                                              41.5

Source: GAO analysis of the 1996 MCBS.




Page 26                                  GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Appendix III

Comments From the Health Care Financing
Administration




               Page 27   GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
Appendix III
Comments From the Health Care Financing
Administration




Page 28                            GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
           Appendix III
           Comments From the Health Care Financing
           Administration




(101786)   Page 29                            GAO/HEHS-99-61 Low-Income Medicare Beneficiaries
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