Pennsylvania
Campaign for Affordable Health Care
FINAL REPORT
September 2003
Lower-income persons on Medicare are generally in poorer health and
tend to have higher healthcare needs, and thus costs.[1] This is because there are many things
Medicare does not cover and many costs to what it does. Many lower-income persons cannot afford
their own healthcare costs and forego needed health care.[2] Studies show that physical health status is
directly linked to whether healthcare is adequate. Lack of prescription drug coverage has been shown to equate to
negative health outcomes. Lack of
adequate healthcare coverage leads to deterioration in health status to the
person and increased costs to the state.
This is because inadequate healthcare coverage can lead to increased
utilization of state funded long-term care, such as nursing homes.
The ability of seniors and persons with disabilities to obtain and
afford adequate healthcare coverage is critical to the health of our
Commonwealth and minimizing strain on publicly funded long term care. Connecting underinsured consumers to
existing programs can be part of a policy that focuses on bringing about good
results while utilizing funds in the most cost effective way. These are significant issues with
significant opportunities to make positive system change.
Research:
States that cover the Part B premium for low income residents
not only save money for the recipients by decreasing their health costs and
increasing their health capital but also save money for the state budgets
through decreased costs in uncompensated care, strain on emergency health
systems, and utilization of long term care services. Further, states save money by shifting some of the health care costs
to the federal government as Medicare could cover many of the individuals who
might otherwise be covered under Medicaid or through the public health
system. These savings are evidenced
both directly and indirectly by studies regarding the uninsured.
Coverage of the Part B premium means regular access to care and higher usage of preventive services.
The Part B premium covers physician visits as well as certain preventive services such as Pap smears, mammograms, and prostate examinations. Coverage of physician visits allows recipients to have access to care outside of the hospital. This is often the difference between an individual with insurance and an individual without insurance. Uninsured, chronically ill people are half as likely to have had a physician’s visit in the past year than those with insurance.[3] Having a regular source of care leads to greater usage of preventive services and disease management, which reduces medical expenditures.[4]
Coverage of preventive services is particularly important in lowering long-term medical costs. Preventive services result in earlier stage diagnosis, which leads to lower medical costs.[5] Unfortunately, individuals who are continuously uninsured have much lower rates of usage of preventive services than those individuals who are insured or are uninsured for only short periods of time.[6] Having health coverage leads to a greater utilization of preventive services.[7]
When Medicare recipients who were previously uninsured began receiving Medicare at age 65, they increased their rate of cholesterol testing by 24.5% and their rate of prostate examinations by 32.3%.[8] One study found that uninsured men were 1.47 times more likely than previously insured men to be diagnosed with prostate cancer at a later stage.[9] Uninsured women with cervical cancer were 60% more likely to be diagnosed with a late stage disease.[10]
Being insured and having regular access to care not only leads to the prevention of diseases and conditions, it also keeps chronic diseases and conditions from developing into more serious and thus more expensive conditions. Diabetes care is another excellent example of how important it is to have regular access to care. In one study, a majority of diabetic emergency room patients were uninsured.[11] Many of these patients visited the emergency room and were later admitted to the hospital for easily reversible and preventable problems relating to their diabetes.[12] However, the vast majority of these patients lacked a primary caregiver and thus were not being monitored by a physician.
Another study found that uninsured individuals with hypertension were 2.4 times more likely to be hospitalized than insured individuals with hypertension.[13] Regular monitoring of chronic diseases like diabetes and hypertension is important in keeping medical costs down.
Even for patients without chronic diseases, regular access to care due to insurance is vital to maintain good health. In a group of patients who were discharged from coverage of routine outpatient care at the Seattle VA Medical Center for budgetary reasons, 41% of patients reported their health to be much worse after 17 months and 47% had reduced their use of prescription drugs. [14] Among those with a blood pressure check after follow up, 41% of the discharged group had uncontrolled high blood pressure, as opposed to 17% of the control group.[15] Regular access to care is extremely important in maintaining good health.
Patients without insurance who therefore lack regular access to care are also more likely to delay seeking care for illnesses.[16] Delays in seeking care result in hospitalization for otherwise controllable or preventable conditions.[17] Overall, 12.3% of hospital stays for the uninsured are for preventable conditions.[18] The uninsured are more likely to be admitted to a hospital for conditions with a higher expected mortality and are more likely to be admitted from the emergency room.[19]
Many coalition members report that consumers who cannot afford the monthly Part B premium or who are not eligible for the state to pay it for them, drop this Part B coverage. As the cost of maintaining Part B coverage skyrockets from $58.70 in 2003 to $66.60 in 2004, we anticipate seeing additional consumers decline or terminate their Part B coverage. By taking steps to insure that consumers maintain Part B Coverage, the Commonwealth would help ensure that patients see a provider regularly. This will, in turn, help patients maintain good health and prevent unnecessary treatment and hospitalizations.
Coverage of the Part B premium will allow Medicare beneficiaries to spend their limited funds on other needs, including those needs not covered by Medicare.
Low-income Medicare beneficiaries spend a high proportion of their income on health expenses. In 1998, the poorest Medicare beneficiaries spent 43% or more of their annual wealth on out of pocket health care expenses.[20] Some of this spending is the Part B premium payment. In 2004, the Part B premium will cost a consumer $800/year. For a consumer at 120% of the federal poverty level, this is 7.5% of their annual income. Coverage of the Part B premium payment for low-income Medicare recipients will free up some of their income for other health care costs such as prescription drugs or a Medicare Gap or HMO policy that will help cover some of the uncovered costs.
Coverage of the Part B premium, which provides for physician’s visits, will decrease the use of safety net providers and reduce the cost of coverage for the state.
When individuals lack regular access to care through a physician’s office, they turn to other sources when they need care. In some areas, the only available source of care is the emergency room of the local hospital. Besides adding to the burden on emergency room services, the cost of using an emergency room is almost twice the cost of using a physician’s office.[21] Other areas have a system of public health clinics, free clinics or other sources of care for the uninsured. However, with the ranks of the uninsured increasing, those safety net providers are becoming less able to provide care. Ensuring that Medicare recipients have Part B coverage and can access physician services through other means can reduce the strain on the safety net providers.
As an example of the strain on safety net providers, a free clinic in Virginia that began as an urgent care facility for the uninsured has seen itself become a primary care site for patients with chronic diseases such as hypertension and diabetes.[22] Patients who could access a physician’s office rather than a clinic that was designed as an urgent care facility would reduce the strain on this clinic’s resources in meeting the needs of its patient population.
Uncompensated care and a lack of insurance for physician visits and preventive services also affects the availability of health care services for those who have coverage.[23] When providers are burdened with the cost of uncompensated care for individuals lacking insurance, they must cut costs in some way. Areas with high rates of uninsurance see lessened access to specialists for all consumers and crowding of emergency departments and other sources of care.[24] When a Medicare recipient can access a physician who is compensated for her services, the entire system of care for that area is helped.
Besides straining resources, uncompensated care for the uninsured costs providers and the state money. The average cost per preventable hospital stay in 2002 by the uninsured was $3,300 for adults.[25] These costs are then borne by the hospitals themselves or by other programs. In 1999, hospitals incurred $20.8 billion, 6.2% of total expenditures in costs for patients who did not pay, which includes the uninsured.[26] One study estimated that by decreasing the number of uninsured by 16%, the demand for uncompenstated hospital care would be reduced by 12%, an estimate of $13 billion between 1997 and 2002.[27]
State and local governments spend an estimated $690 million on health care of the uninsured. [28] Local clinics and other non-hospital programs provided $580 million of this.[29] Community health centers and other direct care providers delivered $7.1 billion to the uninsured in 2001, though more than half of this is from the VA.[30] In 1999, hospitals incurred $20.8 billion, 6.2% of total expenditures in costs for patients who did not pay.[31] Of the approximately $15.6 billion in DSH funds that went to hospitals in 2001, an estimated $8.4 billion is used to cover the uninsured. Of this, $1.7 billion is the states’ contribution.[32]
By paying the Part B premium for low-income Medicare recipients, many of the current costs of their care will be covered by the federal government, thus decreasing the amount expended by the state. In a similar vein, the Commonwealth Foundation recently released a report that estimated that by dropping the 24 month waiting period for SSDI recipients to access Medicare, states would save approximately $1.8 billion, as SSDI recipients covered by Medicaid during the waiting period would be covered by Medicare and the costs paid by the federal government, instead of the state government.[33]
To pay for Part B for a lower-income Medicare beneficiary costs the Department $704/year. For $704 a year, the Department insures that a lower-income person with a disability or who is 65 and older obtains and maintains his or her Medicare Part B, instead of dropping Part B coverage as many would be forced to do.[34]Because Medicare Part B provides medical coverage that includes 80% of the cost of doctor visits and other invaluable medical services, it is invaluable to the Department’s Medical Assistance spend down program, long term care and emergency care budgets to insure that its Medicare population remains in Part B Medicare.
The dual eligible population is a frail population with high healthcare utilization.[35] Dual eligibles who are dually enrolled cost the Medicaid budget less than do persons in the aged, blind, and disabled categories who do not have Medicare. A known cost of $704/person/year to keep these high utilizers enrolled in their primary health care (Medicare) prevents the unknown cost that deterioration in health (caused by lack of health insurance) can toll on the emergency or long term care budgets. Put another way, without medical insurance coverage, people 65 and older and those with disabilities are likely to decline. Many will decline to the point of requiring long term care or emergency room hospitalization, both of which will cost the Department more than $704 per person per year.
Background:
The Pennsylvania Campaign for Affordable
Health Care believes there are numerous reforms needed in the Application Form
for Medicaid Eligibility for Persons with Medicare and in the Application
Process. This report presents
recommendations for change.
The Coalition had many comments about the application process. All felt there are problems with the current process that serve as barriers to enrollment. Generally, the Coalition members felt that the Department needs to eliminate verifications by the consumer, especially where collateral sources of verification information are available.
In brief, the Coalition members felt that the Department needs to:
· Improve the application form and content
· Eliminate verifications by consumer – Can eliminate proofs by better coordinating with state and federal government agencies like: IRS, SSA, Penndot, etc.
· Change or Eliminate the asset test
· Improve renewal process
Changes to The Application Form:
The Medicaid application for Medicare Part B
Premium payment can now be used by Medicare beneficiaries for application into
any Medicaid or other Department of Public Welfare benefit program.[36] Discussion is limited to this form.
The application must be made appealing and accessible. We recommend changes to both the look of the application form. The form looks like a test. It is “boxy and rigorous” and looks “very bureaucratic”. It is too hard to read (especially for the target population) with too small a print size and inadequate white space.
· The application must be made accessible to all applications by employing a larger font size that is of a font recommended for accessibility, yet the most friendly looking font possible.
· The application should not have gray or shaded areas. This does not copy well and is harder for persons with disabilities to read.
· There must be more white space. Again from an accessibility perspective, portions of the application are crowded with text.
· No charts that continue from one page to another – too confusing.
The workgroup has developed a model form for the state to use as an alternative to the form currently used. The model form is attached. It is consistent with the recommendations included herein for look, content, and elimination of verification. It does not contain any changes for asset test change or elimination. A model renewal form is under development.
Eligibility information must be made clear. The application does not make it clear to the applicant whether she would be eligible for the benefits for which she is applying. Consumers do not know federal poverty levels and referring to an “insert” that may or may not come with the application the person is completing is not helpful. Thus, we recommend that the eligibility requirements be spelled out in actual dollar amounts with a note indicating that the dollar amounts are valid for the current year and change each February.
Whose information needs to be reported need to be more clear. The application is not clear on whose information needs to be provided. Only the personal information of the applicant(s) need(s) to be reported. And, only the applicant and their spouse’s income and asset information need to be reported. The application does not make it clear that the applicant could apply for more or have this application considered for more than just Part B Buy-In. Additionally, the application should be screened for eligibility in Food Stamps, PACE, LIHEAP, and Rent Rebate as well as all Medical Assistance programs. The application must prompt information about the possibility of waiver eligibility. At a minimum, a question needs to be included that says something like “Many persons age 65 and older or with disabilities need supportive services in their homes. Programs are available that can provide these services to you at no cost. Would you like to be considered for one of these programs? Yes or No.”
There must be one central address to which completed applications can be sent. The current application does not inform the applicant where to submit the application. Is not clear where the application should be sent. Many applicants have not history of involvement with the CAO and would have no idea where to send their completed application.
The requirement to provide verification should be removed, as discussed below. However, if retained, the Department provide instructions as to how an applicant can obtain the needed verifications. Is not clear how to obtain verifications that must be produced if applicant does not have copies of these.
The application should have a more personal, respectful tone. The application turns applicants off because it doesn’t speak to the person like a person. Other states use words like “we” and “you” and include phrases like, “we cannot treat you differently”.
The application should not use “turn-off” terms like “poverty level”, which intimates “welfare”. Such turn-off terms should not be used. On the question about citizenship, the term “illegal alien” should not be used as it invokes fear, even among lawful immigrants. Instead that 5 options should be changed so that it reads: “1) US Citizen; 2) Permanent Resident Alien; 3) Refugee/Asylee/Parolee; 4) Permanently Residing Under the Color of Law (with the knowledge and permission of the Immigration Service); 5) Other – not eligible for benefits.”
The application form should separate out the explanation information from the application form. Currently, the explanatory and applicant information is combined in such a way that the applicant doesn’t get to keep anything with her after she applies and may not remember what she applied for, etc. Two application should be in two distinct parts: the information describing the program plus how to apply and the application. The info describing the program and giving instructions should be on the front page and should be capable of being torn off to stay with the applicant and the second page should be the application. The application sections should be numbered in coordination with accompanying instructions, to help applicants to understand what is required of them.
The application form should have tag lines in Vietnamese, Chinese, Russian, and Khmer/Cambodian, and Spanish. The tag lines should explain what the application is for and state: “If you need this application in a different language or someone to interpret it, contact your local County Assistance Office.”
The application form should be made available in Vietnamese, Chinese, Russian, and Khmer/Cambodian, as well as in Spanish. In accordance with DHHS’ Title VI Guidance and DPW’s Language Assessment, the application as a vital document should be made available in Vietnamese, Chinese, Russian, and Khmer/Cambodian, as well as in Spanish.
The application form should include questions about the applicant’s preferred spoken and written languages. The English version of the form should ask the applicant: “What language do you speak best?”, “What language do you read best?”, “Do you want an interpreter to help you?” and “In what language?” Also, the persons answering the phone number that is provided on the form as the Help Line number should have access to telephone interpreters. This will ensure that even if the applicant obtained assistance in applying in English, all subsequent communications can be in the appropriate language.
The application form should be made
available in alternative formats and should state that it is available in
alternative formats. It is critical that persons with disabilities
have access to accessible forms for applying for benefits. Denying them access to application forms
they can use poses and unlawful obstacle to their application for
benefits.
ATTACHED you will find a draft application form created by the Application Form and Process Workgroup. It incorporates all of our suggestions and demonstrates how easily these suggestions can be implemented. A CD-ROM with an electronic version is also attached to encourage the Department to use this model without having to recreate it from scratch.
Eliminating Verification by the Consumer:
There are many good reasons for the Department to eliminate the verification requirements, to eliminate the asset test, and to improve the renewal process. Most persuasive is the cost benefit analysis.
The Coalition urges the department
to move to self-declaration by the consumer with verification by the department
using collateral contacts. The consumer
is already signing the application under penalty of perjury and the
insurmountable task of verifying assets and income has posed a significant
barrier to many frail elderly and persons with disabilities becoming enrolled
in this program.
Neither CMS nor federal law requires the state to get verification from applicants. In fact, the CMS encourages reliance on collateral contacts.[37] The Center for Medicare and Medicaid Services has determined that many applicants for healthcare and social services fail to get enrolled because they cannot overcome the administrative hurdles of having to verify all the information needed for the processing of their applications. Much of the information Pennsylvania requires the applicant to provide is not required by federal law. CMS has encouraged states to explore ways to limit or eliminate unnecessary or over burdensome verification requirements. Because so much of the information is independently verifiable by the state, CMS has also encouraged states to shift to self-declaration by the applicant with either a regular or quality assurance based check of self-declaration data from those independent sources. So, for example, instead of requiring an applicant to prove their Social Security income, the state, which has ready access to these records, can check that data. These are mechanisms CMS believes will increase and improve enrollment.
In response, CMS is urging simplification of the enrollment process, CMS reports that:
o 38 states automatically screen for Medicare Savings Program when an applicant applies for any state program.
o 80% of states have simplified their application.[38]
o 11 states use self-declaration of income and resources.
We feel very strongly that the Department move to self-declaration with department verification. To pay for Part B for a lower-income Medicare beneficiary costs the Department $704/year. Ironically, the department unnecessarily spends at least this much on duplicative efforts to verify information.
Much of the verification information the department needs is already available to the department from collateral sources and is already being used by the Department to double check the information that the consumer provided. In fact, discussions with department staff revealed that as much of 80% of the data the consumer is forced to prove is already available from a reliable collateral source and is already being looked at by the Department.[39] For the most part, the Department is requiring the consumer to produce documents proving x, y, or z and is then checking the info through collateral sources anyway. This is costly for the department and unnecessarily burdensome for the consumer. We believe that in most cases this duplication of efforts costs the state more than the value of the benefit to the consumer. Restated, the department is paying more than $705/year to give a consumer a benefit of only $705/year.
Eliminating the verification requirements that are currently imposed on consumers will not only insure that the Medicare population remains covered with medical insurance, it will also reap significant cost savings from an administrative perspective. In states like NY, RI, and MD, significant administrative cost savings have resulted due to improvements (like those we have suggested) in the application process. Most significant is the efficiency of caseworkers. Where consumer verification requirements are eliminated, applications are processed quicker, without caseworkers spending time, postage, and phone bills on hunting down verifications from applicant.[40]
One might be concerned about deception or fraud in trusting consumers to self-declare. The reality is that consumers are not and would not be getting a benefit solely based on their word. Pennsylvania verifies. And, according to CMS’s Medicaid Eligibility Quality Control office, no states that have eliminated asset verification requirements have had any problems with erroneously granting eligibility.
It should also be noted that Pennsylvania’s Pharmaceutical program for the elderly, the PACE program, has just begun using self-declaration. PACE is using SSA data to verify income, age, address, and social security number. The Departments of Aging and Revenue are sharing SSA data from prior years.[41] From this data, the PACE program is able to verify all that it needs to verify. They will require the consumer to produce verification only if the SSA data reveals disparities from the information which was self-declared. The Department of Aging appreciates and anticipates administrative cost savings.
Change or Eliminate the Asset Test:
Because the asset limits for many of the healthcare and supportive services programs have not changed in over 10 years, many low-income persons on Medicare are ineligible for programs that they desperately need. It is unreasonable to expect a frail elder or person with a disability to feel at ease having less than $2000 or even $4000 (for the buy-in programs) to cover any and all home maintenance expenses that might crop up. It is critical that Pennsylvania change or eliminate the asset test for persons in the aged, blind, and disabled category.[42]
In response, 21 states have increased their asset limits and some of these states have allowed self-declaration of assets.[i] Four states, Alabama, Arizona, Delaware, and Mississippi, have eliminated the asset test for Medicare Savings Program applicants altogether.[43] New York and Connecticut have eliminated it only for the QI-1 program. Connecticut dropped the asset test for Q1 and Q2 beneficiaries only as the benefit is fully funded by federal dollars and would not lead to additional costs to the state.[44] Officials there felt that the asset test levels were too high for the target population, as the income levels had increased over the years but the asset test levels had not.[45]
Arizona’s decision to eliminate the asset test was based on a study that included findings that less than 100 applicants per year were being denied on the basis of the asset test and that removing the test would streamline the process for the Medicaid agency, thereby reducing staff time.[46]
Other states have liberalized their asset tests for the Medicare Savings Programs in other ways. Three states choose to disregard a portion of countable assets. Minnesota disregards the first $10,000 of countable assets for an individual and $18,000 for a couple, Maine excludes the first $8,000 for an individual and $12,000 for a couple and Florida disregards the first $1,000 for both groups.[47] Five other states, including Kansas, Maine and South Carolina, will find applicants eligible if their assets are within the guidelines at any point during the month.[48] Finally, other states will disregard certain property. Georgia, for example, disregards a higher amount of life insurance, a higher amount of burial funds, two or more vehicles, and all household goods and personal effects.[49] Others have used new federal flexibility to permit applicants to set aside a home maintenance account that is not included in countable assets. Pennsylvania must take steps to eliminate this barrier through increased asset limits or, in some cases, eliminated asset tests.
We believe the Department should eliminate completely the asset test for
persons over 65 and adults with permanent disabilities. However, at a minimum the asset test must be
changed. The asset limit must be
increased. According to a report
completed by Marilyn Moon in June 2002 (Medicare Beneficiaries adn Their
Assets: Implications for Low-Income Programs), a $10,000 asset
disregard would result in making approximately 80% of all Medicare
beneficiaries with incomes up to 175% of poverty eligible for MSPs. According to the study (which you may
already be familiar with), nearly 85% of all beneficiaries with incomes at or
below 100% of poverty have assets less than $12,000 as do 80% of
beneficiaries with incomes up to 175% of poverty.
While complete elimination of the asset test is recommended, the asset test for persons over 65 and adults with permanent disabilities should be raised to no less than $10,000.
Currently, there is no standard reapplication notice being used by all CAOs informing enrollees of the need to reapply for Part B. Part B Buy-In is the only Medical Assistance program for which the applicant must complete the entire MA application again to renew.
While it is hard enough to find out about and then become
enrolled in available programs, it is very easy to be dropped from these
programs. Having to complete an
entirely new application for a program each year just to remain enrolled is
confusing to many and burdensome to all.
States have tried different strategies in simplifying their
re-enrollment procedures. Utah will
automatically re-enroll recipients and requires nothing from them unless there
is evidence that the recipient is ineligible.[50] Other states, such as Connecticut,
have implemented an automatic enrollment process whereby a recipient is
automatically sent a renewal form which they must fill out and send back to the
agency, along with any required documentation.
Some states, such as Minnesota, have not been satisfied with this
process and are considering creating a pre-printed postcard with the
recipient’s financial information that would only need to be amended with
updated information, signed and returned to the department.[51] Other states, such as Washington, have
attempted to streamline their re-enrollment process by allowing
self-declaration of assets and income.[52] CMS has encouraged the use of passive
enrollment and similar strategies that help the consumer remain enrolled. CMS reports that 95% of the states have
streamlined their redetermination process.
Because too many Pennsylvanians who overcome the barriers
and get enrolled lose enrollment because of an unnecessarily complicated
renewal process, Pennsylvania must ease the renewal process so that it becomes
harder to disenroll than to reenroll.
Additionally, the administrative
costs incurred on a renewal process that replicates the entire application
process are large. The doubled costs of
requiring the consumers to verify their information and then going out and
verifying it independently will be incurred each year, for as long as this
cumbersome renewal process continues.
Conclusion:
It is imperative that the State
take steps to eliminate the barriers to enrollment for adults with disabilities
and those over 65 into healthcare and buy-in programs. Doing so will reduce administrative waste,
improve administrative efficiency, reduce emergency room and health center
utilization, reduce long term care costs, and increase health and life
expectancy of consumers. This report
not only demonstrates that the Department would realize critical savings and
positive impacts but also articulates how these savings and positive impacts ca
be achieved.
Written and prepared by Alissa Eden Halperin, Esq.
Managing Attorney
PA Health Law Project
And
Project Manager
PA Campaign for Affordable Health Care
[1] Families USA – Presentation by Rachel Klein of Families USA, October 16, 2003.
[2] Ibid. 25% of seniors report skipping doses or not filling prescriptions because of cost.
[3] Jack Hadley. Sicker and Poorer: The Consequences of being Uninsured. Kaiser Commission on Medicaid and the Uninsured. May 2002. p.36
[4] Stephen T. Parente and William N. Evans. (1998) Effect of Low-Income Elderly Insurance Copayment Subsidies. Health Care Financing Review. 20(2):19-37.
[5] Heather L. Bednarek and Barbara Steinberg Schone. (2003) Variation in Preventive Service Use Among the Insured and Uninsured: Does Length of Time Without Coverage Matter? Journal of Health Care of the Poor and Undeserved. 14(3):403-419.
[6] Bednarek
[7] J. Michael McWilliams et al. (2003) Impact of Medicare Coverage on Basic Clinical Services of Previously Uninsured Adults. JAMA 290(6):757-764.
[8] J. Michael McWilliams et al. (2003) Impact of Medicare Coverage on Basic Clinical Services of Previously Uninsured Adults. JAMA 290(6):757-764.
[9] No Health Insurance? It’s Enough to Make you Sick- Scientific Research Linking the Lack of Coverage to Poor Health. (1999) American College of Physicians. p.27
[10] Id. at 19.
[11] Bruce E. Wilson and Ashish Sharma. (1995) Public Cost and Access to Primary Care for Hyperglycemic Emergencies, Clark County Nevada. Journal of Community Health. 20(3):249-256.
[12] Bruce E. Wilson and Ashish Sharma. (1995) Public Cost and Access to Primary Care for Hyperglycemic Emergencies, Clark County Nevada. Journal of Community Health. 20(3):249-256
[13] No Health Insurance? It’s Enough to Make you Sick- Scientific Research Linking the Lack of Coverage to Poor Health. (1999) American College of Physicians p.11
[14] Jack Hadley. Sicker and Poorer: The Consequences of being Uninsured. Kaiser Commission on Medicaid and the Uninsured. May 2002. p.43
[15] Jack Hadley. Sicker and Poorer: The Consequences of being Uninsured. Kaiser Commission on Medicaid and the Uninsured. May 2002. p.43
[16] No Health Insurance? It’s Enough to Make you Sick- Scientific Research Linking the Lack of Coverage to Poor Health. (1999) American College of Physicians. p.11
[17] No Health Insurance? It’s Enough to Make you Sick- Scientific Research Linking the Lack of Coverage to Poor Health. (1999) American College of Physicians. p.7
[18] Jack Hadley. Sicker and Poorer: The Consequences of being Uninsured. Kaiser Commission on Medicaid and the Uninsured. May 2002 p.77
[19] Jack Hadley. Sicker and Poorer: The Consequences of being Uninsured. Kaiser Commission on Medicaid and the Uninsured. May 2002. p.42
[20] Dana P. Goldman and Julie M. Zissimopoulos.. High Out-Of-Pocket Spending by the Elderly. Health Affairs. May/June 2003, 22(3):194-202.
[21] No Health Insurance? It’s Enough to Make you Sick- Scientific Research Linking the Lack of Coverage to Poor Health. (1999) American College of Physicians. P. 9
[22] Mohan M. Nadkarni and John T. Philbrick (2003). Free Clinics and the Uninsured: The Increasing Demands of Chronic Illness. Journal of Health Care for the Poor and Underserved. 14(2):165-174.
[23] Institute of Medicine. (2003). Hidden Costs, Value Lost: Uninsurance in America. National Academies Press. p.89
[24] Institute of Medicine. (2003). Hidden Costs, Value Lost: Uninsurance in America. National Academies Press. p.89
[25] Jack Hadley. Sicker and Poorer: The Consequences of being Uninsured. Kaiser Commission on Medicaid and the Uninsured. May 2002 p.78
[26] Jack Hadley and John Holahan. “How Much Medical Care do the Uninsured Use and Who Pays for it?” Health Affairs.Web Exclusive. February 2003 p.W3-70
[27] Kenneth E. Thorpe. (1997). Incremental Strategies for Providing Health Insurance for the Uninsured: Projected Federal Costs and Number of Newly Insured. JAMA. 278(4):329-333.
[28] Jack Hadley and John Holahan. Who Pays and How Much? The cost of caring for the uninsured. Washington, DC: The Urban Institute. February 2003. p.56-57
[29] Jack Hadley and John Holahan. Who Pays and How Much? The cost of caring for the uninsured. Washington, DC: The Urban Institute. February 2003. p.56-57
[30] Jack Hadley and John Holahan. “How Much Medical Care do the Uninsured Use and Who Pays for it?” Health Affairs.Web Exclusive. February 2003. p.W3-71
[31] Jack Hadley and John Holahan. “How Much Medical Care do the Uninsured Use and Who Pays for it?” Health Affairs.Web Exclusive. February 2003. p.W3-70
[32] Jack Hadley and John Holahan. Who Pays and How Much? The cost of caring for the uninsured. Washington, DC: The Urban Institute. February 2003. p.40
[33] Stacy Berg Dale and James M. Verdier. Elimination of Medicare’s Waiting Period for Seriously Disabled Adults: Impact on Coverage and Costs. The Commonwealth Fund. July 2003
[34] It should be noted that a consumer who declines Part B when the first become eligible faces large penalties that mount for every year they are not enrolled. A consumer who declines now because she cannot afford the cost of $58.70/mo but decides in 5 years that she wants to enroll in Part B would pay the then Part B premium amount plus 10% of the monthly premium for each year she was not enrolled. A person who failed to enroll 5 years ago would now have to pay $58.70 + $5.87 + $5.87 + $5.87 + $5.87 + $5.87 = $88.05/mo if they want to enroll now in Part B. That amounts to $1057 per year.
[35] CITE
[36] Any Form is a Good Form policy clarification, dated March 25, 2003.
[37] Centers for Medicare and Medicaid Services. (2001) Continuing the Progress: Enrolling and Retaining Low-Income Families and Children in Health Care Coverage. (Hereinafter, Continuing the Progress)
[38] This includes Pennsylvania.
[39] The Department of Public Welfare has access to
several sets of data for verifying the information that the applicant
provides. The Department does matches
with data from the SSA, the Veterans Administration, Labor & Industry (for
wages and UC), the IRS, the Department of Health (for deceased persons), and
Interstate Match. They are not
currently doing matches with Penndot or the Department of Revenue. SSA information. The Department has access to both prior years SSA data and
current SSA data. The current SSA data
is available on request. In fact, all
new applications are run through the SSA current data for an SSA match if they
have SSA income. The current SSA data
match reveals: current income from SSA, SSI, or SSDI and date of birth. The previous years data and or the SSA
mismatch report data would be available to verify age, address, and SS#. IRS information. The Department gets IRS match information that shows an
applicant’s prior year’s income and assets. DPW doesn’t get any info from Penndot to confirm id/address/ or
vehicle ownership.
The Department is already confirming the following
through collateral sources:
1.
DOB
1.
Prior year’s address
1.
Income from all sources
1.
identification of
assets, although not necessarily asset value
1.
Social Security number
[40] And, this does not include any time that might be spent were the caseworker to actually assist the consumer in tracking down verifications, which, although they are required to do (in some circumstances), few caseworkers actually do.
[41] At a total cost of $12,000.
[42] Technically, there is no way to “eliminate” an asset test. A state would have to make a state plan amendment seeking to “disregard” all or some assets for an elimination or increase of the asset test to occur.
[43] Laura Summers and Robert Friedland, “The Role of the Asset Test in Targeting Benefits for Medicare Savings Programs”, Georgetown University, October 2002. p.3
[44] Glaun, Kim. Medicaid Programs to Assist Low-Income Medicare Beneficiaries: Working Paper on Medicare Savings Programs in Connecticut. The Kaiser Commission on Medicaid and the Uninsured. December 2002 p.4
[45]. Id.
[46] Glaun, Kim. Medicaid Programs to Assist Low-Income Medicare Beneficiaries: Working Paper on Medicare Savings Programs in Arizona. The Kaiser Commission on Medicaid and the Uninsured. December 2002 p.4
[47] Laura Summers and Robert Friedland, “The Role of the Asset Test in Targeting Benefits for Medicare Savings Programs”, Georgetown University, October 2002. p.4
[48] Id.
[49] Id.
[50] Nemore, Patrica. Variations in State Medicaid Buy-in Practices for Low Income Medicare Beneficiaries: A 1999 Update. Henry J. Kaiser Foundation. December 1999. p.17
[51] Glaun, Kim.. Medicaid Programs to Assist Low-Income Medicare Beneficiaries: Working Paper on Medicare Savings Programs in Minnesota. The Kaiser Commission on Medicaid and the Uninsured. December 2002 p.9
[52] Glaun, Kim. (2002) Medicaid Programs to Assist Low-Income Medicare Beneficiaries: Working Paper on Medicare Savings Programs in Washington. The Kaiser Commission on Medicaid and the Uninsured p.8