July 22, 2025 • 21 mins
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Health Affairs' Rob Lott interviews J. Wyatt Koma of Harvard University about his recent paper that explores enrollment trends and characteristics of low-income beneficiaries within Medicare Savings Programs.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:00):
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. The Medicarepopulation is incredibly
diverse, including, of coursepeople aged 65 and older, as
well as younger individuals withdisabilities. It spans all
races, ethnicities, andgeographic areas from residents
(00:27):
of big cities to those in ruraltowns. It also reaches people at
all income levels, the wealthy,the poor, and everyone in
between.
And so for a subset of theMedicare population, those with
low incomes and limited savings,the premiums and cost sharing
(00:47):
can impose a significant burden.And it's with that burden in
mind that Congress created fourMedicare savings programs
specifically designed to helplow income beneficiaries afford
the out of pocket costsassociated with securing
coverage and receiving carethrough Medicare. But what do we
(01:09):
actually know about the peoplewho take advantage of the
Medicare Savings Program? Andwhat can we learn from how that
population may have changed overthe years? That's the subject of
today's Health Policy.
I'm here with Jay Wyatt Coma, aPhD candidate in the Health
Policy Program at HarvardUniversity. Together with co
(01:31):
authors, he has a paper in theJuly issue of Health Affairs
titled, Qualified MedicareEnrollment Trends and
Characteristics of Low IncomeBeneficiaries. I can't wait to
hear more about their findingsand to learn more about its
lessons for policymakers goingforward. Wyatt Coma, welcome to
(01:55):
the PODCY.
J. Wyatt Koma (01:56):
Thank you so much for having me.
Rob Lott (01:58):
All right, well, let's just jump right in, with some
background. When was theMedicare Savings Program created
and why was it necessary in thefirst place? I described a
little bit of the sort of thecontext of low income
beneficiaries. Is that aadequate description of the
program and what else was goingon there?
J. Wyatt Koma (02:21):
Yeah, it's a great question. Congress created
four Medicare Savings Programbetween 1988 and 1997 to help
low income Medicarebeneficiaries pay for their
Medicare Parts A and B premiumsand cost sharing. I think first
it's helpful to make sure thatwe have the kind of a background
on Medicare Parts A and B. SoMedicare Part B is a voluntary
(02:44):
benefit that covers people'sdoctor's visits and other
outpatient care. Andbeneficiaries who receive their
coverage through traditionalMedicare are expected to pay a
premium for their Part Bcoverage.
Whereas for Medicare Part A,it's generally coverage for care
received in hospitals and it'susually premium free for most
(03:04):
Medicare beneficiaries afterthey work long enough. And
really, you brought this up, butthe cost sharing in Medicare can
be substantial includingdeductibles and coinsurance in
parts A and B. And it'simportant to note that there is
no max on how much people withMedicare can spend out of pocket
in traditional Medicare. Reallygiven the sizable cost sharing,
(03:27):
that's why the Medicare SavingsPrograms were introduced. And
they're administered by stateMedicaid programs.
And their goal is really to helpbeneficiaries pay these premiums
and cost sharing. And sincethese programs are administered
by states, there is somevariation in the eligibility
criteria. Although all of theMedicare Savings Programs do
have to adhere to the federalminimum standards. And so for
(03:50):
2025, the asset limit for a yearto qualify for the Medicare
Savings Program, which includespeople's savings and investments
like stocks and bonds was around$9,500 for an individual and
around $14,000 for a couple.
Rob Lott (04:07):
Got it, okay. And so I think you said the first program
was created in 1989. And so it'sbeen around, let's see, doing
some quick math here, thirtyfive, thirty six years. What do
we know about how well theprogram is working? How well
does it achieve its goals and inwhat ways maybe does it fall
(04:28):
short?
J. Wyatt Koma (04:30):
Yeah, I mean, so it's important to note that
about 10,000,000 low incomepeople with Medicare were
enrolled in one of the MedicareSavings Program eligibility
groups in 2021. And we know thatthese low income people who
qualify for Medicare SavingsPrograms are more often eligible
for Medicare because of thedisability rather than age.
They're also more likely to befrom racially or ethnically
(04:52):
minoritized communities and theyalso tend to have worse health
outcomes than their higherincome counterparts. And we also
know that beneficiaries who aredually eligible for Medicare and
Medicaid, including those inMedicare Savings Programs, are
also automatically enrolled inthe Medicare Part D Low Income
Subsidy Program. And so MedicarePart D covers prescription drugs
(05:15):
and the Low Income SubsidyProgram helps beneficiaries
afford their Medicare Part Dpremiums and the cost sharing
for those drugs.
So really the combination of theMedicare Savings Program and LIS
benefits can really becritically important for
reducing cost related barriersto both medical care and
prescription drugs for thesehigh need populations. That
(05:39):
said, evidence suggests thatthis assistance, particularly
the QMB program or the qualifiedMedicare beneficiary program
does improve access to care andit does reduce financial
burdens. And we know that about80% of the Medicare Savings
Program enrollees are enrolledin the Quimby Group and about
(06:00):
the remaining 20 other percentof low income beneficiaries in
Medicare Savings Program areenrolled in a different
eligibility group that reallyonly covers premiums for parts A
and B. And all that said, thereis robust literature now
documenting low take up sincethe creation of the Medicare
(06:22):
Savings Program. And take up isthe percentage of the eligible
population that's actually endsup enrolled in the program.
Rob Lott (06:29):
I imagine there might also be some complexity around
the fact that there's more thanone program. Like you said,
qualified Medicare beneficiaryprogram, QMB represents I think
about 80% of the beneficiariesin the Medicare savings program.
Can you describe the differentmodels and sort of explain why
(06:51):
do we even need more than one?What's going on there?
J. Wyatt Koma (06:55):
Yeah, that's a great question. So as we were
talking about, the first andlargest Medicare Savings Program
eligibility group is thequalified Medicare beneficiary
program. And so it's got anincome limit of around 100% of
the federal poverty level, whichis about $1,300 per month for a
person in 2025. And so the QMBprogram pays beneficiary
(07:20):
premiums and their cost sharing,which we talked about before,
which includes deductibles andcoinsurance and co payments. And
then the other three MedicareSavings Program eligibility
groups really only helpbeneficiaries pay either their
part A or their part B premiums,but don't help beneficiaries
with their cost sharing.
Rob Lott (07:40):
Do you have a sense that, so my understanding is
that these were sort of createdover time. And I mean, do you
have a sense that maybe ifsomeone kind of wiped the slate
clean and wanted to create aprogram, a Medicare savings
program from scratch today, itmight not be quite as fragmented
(08:01):
as the current status quo?
J. Wyatt Koma (08:05):
Yeah, I'm sure that if people could go back,
they would wipe the slate cleana little bit and make a more
streamlined process forenrollment and as more
streamlined program itself. Theywere introduced over about a
decade and really they were eacheligibility group was introduced
as like a patchwork solution fora problem at the time that the
(08:28):
legislation was introduced. Youknow, it's confusing just
talking about it. There's a lotof words and a lot of word
salad, and I think it kind ofmakes sense why people with
Medicare are confused by theprogram and what is required to
enroll.
Rob Lott (08:41):
Okay. Well, against this backdrop, why don't you
tell us about your paper? I knowyou looked at the Quimby model.
What variables did you measureand what did you find?
J. Wyatt Koma (08:51):
Yeah, so we assessed take up of the Quimby
Medicare Savings Program usingthe most recent data of the
Medicare Current Beneficiarysurvey from 2016 to 2022. And
since the QMB eligibility groupis the largest and most
expansive in coverage, it'sparticularly of interest to
policymakers. And so that's whywe focused on that eligibility
(09:13):
group in particular. And so inour analysis, we first
identified Medicarebeneficiaries who were likely
eligible for the Quimby programbased on their reported income
and assets. And then among thatgroup, we assessed Quimby
enrollment using administrativeenrollment data from CMS that's
linked to the survey data.
(09:34):
So we then compared who isenrolling and the cost related
barriers to care among eligiblebeneficiaries who were enrolled
versus those who were notenrolled in the program.
Rob Lott (09:46):
Got it. Okay. And what'd you find?
J. Wyatt Koma (09:48):
Yeah. So our first set of findings was really
about the take up rate of theQuimby program. And we found
that roughly two thirds ofpeople who were eligible for the
Quimby group were enrolled in2022. We found that an
additional 17% of low incomepeople who were eligible for the
Quimby program were enrolled insome other program, either a
different Medicare SavingsProgram eligibility group, they
(10:10):
were enrolled in full benefitMedicaid, or they were enrolled
in the Medicare Part D LowIncome Subsidy program by
itself. And then the remaining17%, so one in six eligible, QMB
eligible beneficiaries were notenrolled in any of these
programs in 2022.
And so these people with lowincomes were fully exposed to
(10:31):
Medicare cost sharing andpremiums.
Rob Lott (10:33):
I wanna ask you a little more to look under the
hood there in those findings.But before we do, let's take a
quick break. And we're back. I'mhere with Wyatt Coma talking
(11:38):
about the Qualified MedicareBeneficiary Program. So Wyatt, I
think one of the key findings inthe paper is that there was
actually a slight increase inthe proportion of enrollees in
this program.
And I'm wondering if you can saya little more about how
significant that was and whatyou might attribute that
(12:01):
increase to.
J. Wyatt Koma (12:02):
You're right. We do see a slight uptick in take
up of the Quimby eligibilitygroup over the study timeline
from roughly sixty two percentin 2016 to sixty six percent in
2022. And so we don'tspecifically evaluate what
contributed to these changesover time, but there were a
couple of possible explanations.So for one, most states expanded
(12:26):
Medicaid to low income childlessadults under the ACA expansion
pathway since 2014, and thatincluded nine states during our
study period. And our analysisfinds that people who live in
ACA expansion states are morelikely to enroll in QMP than
those who live in non expansionstates.
Rob Lott (12:43):
Is that sort of a kind of I think they call it the
doormat effect kind of when whenpeople are kind of seeing and
hearing promotions about allkinds of different programs,
they kind of start to do theirown research and figure out what
they're eligible for. Is thatkind of your suspicion? What's
going on there?
J. Wyatt Koma (13:02):
Yeah, it could definitely be a piece of the
welcome mat effect. It's worthnoting though that while these
low income Medicarebeneficiaries aren't eligible
for Medicaid through this ACApathway, having Medicaid
enrollment before they enterMedicare might end up increasing
QMB take up if these enrolleeshave, like you said, a greater
awareness of the availableassistance or if they receive
(13:25):
outreach or support totransition to a Medicare savings
program once they enterMedicare.
Rob Lott (13:31):
Got it. Okay. Any other theories or factors that
you identified as sort ofcontributing to that increase?
J. Wyatt Koma (13:40):
Yeah. So I would say the final reason that we
were thinking through was we dosee the highest QMV take up
rates in our study period from2020 to 2022, which was also
when states halted Medicaidredeterminations during the
COVID-nineteen public healthemergency. And so more work is
needed to really assess if thesetake up rates persist after the
(14:04):
2023 to 2025 Medicaid unwinding.
Rob Lott (14:08):
Okay, great. A good future research question you and
your colleagues to come back to.At this point, I'm wondering if
you can tell us a little bitabout the 2023 rule that came
from CMS aimed at streamliningenrollment in these programs.
What does the rule try toachieve and what's the timeline
(14:31):
at this point forimplementation?
J. Wyatt Koma (14:33):
The 2023 CMS final rule was an attempt by the
Biden administration to reducethese barriers to enrollment
that we're seeing in theMedicare Savings Program for
people with low incomes. And soreally broadly, it does two
things. One, the rule includesrequirements for states that
already automatically enrollsupplemental security income or
(14:55):
SSI recipients into Medicaid tothen also automatically enroll
these SSI recipients into theQMB program by October. And then
two, the rule tries tostreamline eligibility and
enrollment information betweenthe QMB program and the Medicare
Part D Low Income Subsidyprogram, which lowers drug costs
(15:18):
for enrollees. And so morespecifically, the rule tries to
encourage states to aligneligibility criteria between the
Medicare Part D LIS and the QMBQMB program.
And then it requires states touse the income and assets data
from the Part D LIS applicationsin new Medicare Savings Program
(15:39):
applications by April. And sooverall, back to our patchwork
discussions of low incomesupport for Medicare
beneficiaries, this rulebasically tries to streamline
enrollment into the Quimbyprogram and other Medicare
Savings Eligibility Groups withother low income assistance
programs that have a super largeoverlap in the eligible
(16:01):
population. And it kind ofrequires states to auto enroll
or use existing eligibility datawhere possible, which really
could make it easier for peopleto enroll and then also could
reduce costs for state Medicaidprograms.
Rob Lott (16:15):
Got it. Okay, seems like a pretty straightforward
and reasonable attempt atreducing some of that
bureaucratic burden andinefficiency to get people who
are eligible into the system.How might your paper shed some
light on the implementationprocess for this rule. In other
(16:36):
words, is there relevance fromyour findings to the people at
CMS who are charged with puttingthis rule into effect?
J. Wyatt Koma (16:45):
Yep, we definitely hope so. We wrote
this paper to try and informpolicymakers who were trying to
improve enrollment in the QMBprogram. So our findings do a
few things. One, we provide themost recent estimates of QMB
take up and find that while takeup rates have increased, one in
three eligible people have notenrolled. And then two, we
(17:06):
provide some demographiccharacteristics of who is and is
not enrolling in the Quimbyprogram, which hopefully could
inform some targeted outreachstrategies.
And three, our findings supportprior evidence that shows that
the Quimby eligibility groupsreally do help to reduce
financial barriers to care. Andadditionally, these data help to
(17:29):
provide estimates of thepotential impact of the 2023 CMS
final rule. So for example, in2022, six percent of QMB
eligible beneficiaries wereenrolled in full benefit
Medicaid and not enrolled in anyMSP. Under the new rule,
beneficiaries, the six percentof these beneficiaries who
(17:50):
receive SSI would beautomatically enrolled in the
Quimby program in the 35 statesthat automatically enroll SSI
recipients into Medicaid. And wealso found that 3% of QMB
eligible beneficiaries in 2022were enrolled in Medicare Part D
low income subsidy only.
(18:11):
And so the CMS rule encourages,but doesn't require states to
fully align income and assetcounting rules between these two
programs. And so greater stateadoption of the LIS eligibility
rules with the MSP eligibilityrules could facilitate enrolling
a greater share of theseenrollees using data from the
(18:33):
LIS applications. All that saidthough, the current
administration's focus oncutting Medicaid costs could
have a lot of implications forthe future of the CMS rule. CDO
estimates that repealing thesestreamlined enrollment
provisions would result inreductions in enrollment in the
Medicare Savings Program bypotentially millions of
(18:55):
beneficiaries by 02/1934. And soreally these Medicaid
eligibility and enrollmentpolicies need to carefully weigh
the potential impact on lowincome people with Medicare with
any potential cost savings.
Rob Lott (19:08):
Gotcha. You mentioned that CBO estimate. Is that
because there are potential cutsin the Republican reconciliation
package that's moving throughCongress?
J. Wyatt Koma (19:20):
One of the cuts would repeal the 2023 final
rule.
Rob Lott (19:25):
Okay. So before we wrap up, let's take a step back
for our listeners thinking aboutwhere we go from here. What do
you see as the next step interms of policy? And if your
paper were to sort of inspireconcrete specific policy change
going forward in this space,what would that be?
J. Wyatt Koma (19:46):
So I think it's important to first say that
Medicare covers sixty fourmillion older adults and people
with disabilities and that helpsthem access healthcare. But this
coverage can be unaffordable,particularly for those with
modest income and assets. And sothe Medicare Savings Program and
the Quimby Eligibility Group inparticular can really help low
income Americans with Medicareaccess healthcare by making it
(20:08):
more affordable. So in terms ofnext steps for policy, we really
see maintaining the twentytwenty three final rule as a
critical first step tostreamlining enrollment across
these low income programs forMedicare beneficiaries. That
said, we do have some additionalrecommendations as a way to
build on the twenty twenty threefinal rule.
(20:29):
So for example, strongerrequirements for alignment
between the Medicare SavingsProgram eligibility groups and
the Medicare Part D Low IncomeSubsidy could really improve
access to available assistancefor low income beneficiaries and
could reduce administrativecosts for both beneficiaries and
the state Medicaid programs. Butit's important to underscore
(20:49):
that this final rule really onlyimpacts people with Medicaid who
are already enrolled in one ofthe low income programs. And our
analysis finds that nearly onein six of these eligible people
are not enrolled in any of thelow income programs. So
additional outreach andeducation is really needed to
beneficiaries who aren'timpacted by the final rule and
(21:09):
may be the least aware and toface the greatest barriers to
enrolling in the MedicareSavings Program.
Rob Lott (21:15):
Well, that's a great spot perhaps to wrap up. Wyatt
Coma, thank you so much formaking the time to chat with us
today and for sharing yourfindings with us. Thank you
J. Wyatt Koma (21:26):
so much for having me.
Rob Lott (21:27):
To our listeners, if you enjoyed the episode, please
share it with a friend, leave areview, subscribe, and of course
tune in next week. Thanks forlistening. If you enjoyed
today's episode, I hope you'lltell a friend about a health
policy.
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. The Medicarepopulation is incredibly
diverse, including, of coursepeople aged 65 and older, as
well as younger individuals withdisabilities. It spans all
races, ethnicities, andgeographic areas from residents
(00:27):
of big cities to those in ruraltowns. It also reaches people at
all income levels, the wealthy,the poor, and everyone in
between.
And so for a subset of theMedicare population, those with
low incomes and limited savings,the premiums and cost sharing
(00:47):
can impose a significant burden.And it's with that burden in
mind that Congress created fourMedicare savings programs
specifically designed to helplow income beneficiaries afford
the out of pocket costsassociated with securing
coverage and receiving carethrough Medicare. But what do we
(01:09):
actually know about the peoplewho take advantage of the
Medicare Savings Program? Andwhat can we learn from how that
population may have changed overthe years? That's the subject of
today's Health Policy.
I'm here with Jay Wyatt Coma, aPhD candidate in the Health
Policy Program at HarvardUniversity. Together with co
(01:31):
authors, he has a paper in theJuly issue of Health Affairs
titled, Qualified MedicareEnrollment Trends and
Characteristics of Low IncomeBeneficiaries. I can't wait to
hear more about their findingsand to learn more about its
lessons for policymakers goingforward. Wyatt Coma, welcome to
(01:55):
the PODCY.
J. Wyatt Koma (01:56):
Thank you so much for having me.
Rob Lott (01:58):
All right, well, let's just jump right in, with some
background. When was theMedicare Savings Program created
and why was it necessary in thefirst place? I described a
little bit of the sort of thecontext of low income
beneficiaries. Is that aadequate description of the
program and what else was goingon there?
J. Wyatt Koma (02:21):
Yeah, it's a great question. Congress created
four Medicare Savings Programbetween 1988 and 1997 to help
low income Medicarebeneficiaries pay for their
Medicare Parts A and B premiumsand cost sharing. I think first
it's helpful to make sure thatwe have the kind of a background
on Medicare Parts A and B. SoMedicare Part B is a voluntary
(02:44):
benefit that covers people'sdoctor's visits and other
outpatient care. Andbeneficiaries who receive their
coverage through traditionalMedicare are expected to pay a
premium for their Part Bcoverage.
Whereas for Medicare Part A,it's generally coverage for care
received in hospitals and it'susually premium free for most
(03:04):
Medicare beneficiaries afterthey work long enough. And
really, you brought this up, butthe cost sharing in Medicare can
be substantial includingdeductibles and coinsurance in
parts A and B. And it'simportant to note that there is
no max on how much people withMedicare can spend out of pocket
in traditional Medicare. Reallygiven the sizable cost sharing,
(03:27):
that's why the Medicare SavingsPrograms were introduced. And
they're administered by stateMedicaid programs.
And their goal is really to helpbeneficiaries pay these premiums
and cost sharing. And sincethese programs are administered
by states, there is somevariation in the eligibility
criteria. Although all of theMedicare Savings Programs do
have to adhere to the federalminimum standards. And so for
(03:50):
2025, the asset limit for a yearto qualify for the Medicare
Savings Program, which includespeople's savings and investments
like stocks and bonds was around$9,500 for an individual and
around $14,000 for a couple.
Rob Lott (04:07):
Got it, okay. And so I think you said the first program
was created in 1989. And so it'sbeen around, let's see, doing
some quick math here, thirtyfive, thirty six years. What do
we know about how well theprogram is working? How well
does it achieve its goals and inwhat ways maybe does it fall
(04:28):
short?
J. Wyatt Koma (04:30):
Yeah, I mean, so it's important to note that
about 10,000,000 low incomepeople with Medicare were
enrolled in one of the MedicareSavings Program eligibility
groups in 2021. And we know thatthese low income people who
qualify for Medicare SavingsPrograms are more often eligible
for Medicare because of thedisability rather than age.
They're also more likely to befrom racially or ethnically
(04:52):
minoritized communities and theyalso tend to have worse health
outcomes than their higherincome counterparts. And we also
know that beneficiaries who aredually eligible for Medicare and
Medicaid, including those inMedicare Savings Programs, are
also automatically enrolled inthe Medicare Part D Low Income
Subsidy Program. And so MedicarePart D covers prescription drugs
(05:15):
and the Low Income SubsidyProgram helps beneficiaries
afford their Medicare Part Dpremiums and the cost sharing
for those drugs.
So really the combination of theMedicare Savings Program and LIS
benefits can really becritically important for
reducing cost related barriersto both medical care and
prescription drugs for thesehigh need populations. That
(05:39):
said, evidence suggests thatthis assistance, particularly
the QMB program or the qualifiedMedicare beneficiary program
does improve access to care andit does reduce financial
burdens. And we know that about80% of the Medicare Savings
Program enrollees are enrolledin the Quimby Group and about
(06:00):
the remaining 20 other percentof low income beneficiaries in
Medicare Savings Program areenrolled in a different
eligibility group that reallyonly covers premiums for parts A
and B. And all that said, thereis robust literature now
documenting low take up sincethe creation of the Medicare
(06:22):
Savings Program. And take up isthe percentage of the eligible
population that's actually endsup enrolled in the program.
Rob Lott (06:29):
I imagine there might also be some complexity around
the fact that there's more thanone program. Like you said,
qualified Medicare beneficiaryprogram, QMB represents I think
about 80% of the beneficiariesin the Medicare savings program.
Can you describe the differentmodels and sort of explain why
(06:51):
do we even need more than one?What's going on there?
J. Wyatt Koma (06:55):
Yeah, that's a great question. So as we were
talking about, the first andlargest Medicare Savings Program
eligibility group is thequalified Medicare beneficiary
program. And so it's got anincome limit of around 100% of
the federal poverty level, whichis about $1,300 per month for a
person in 2025. And so the QMBprogram pays beneficiary
(07:20):
premiums and their cost sharing,which we talked about before,
which includes deductibles andcoinsurance and co payments. And
then the other three MedicareSavings Program eligibility
groups really only helpbeneficiaries pay either their
part A or their part B premiums,but don't help beneficiaries
with their cost sharing.
Rob Lott (07:40):
Do you have a sense that, so my understanding is
that these were sort of createdover time. And I mean, do you
have a sense that maybe ifsomeone kind of wiped the slate
clean and wanted to create aprogram, a Medicare savings
program from scratch today, itmight not be quite as fragmented
(08:01):
as the current status quo?
J. Wyatt Koma (08:05):
Yeah, I'm sure that if people could go back,
they would wipe the slate cleana little bit and make a more
streamlined process forenrollment and as more
streamlined program itself. Theywere introduced over about a
decade and really they were eacheligibility group was introduced
as like a patchwork solution fora problem at the time that the
(08:28):
legislation was introduced. Youknow, it's confusing just
talking about it. There's a lotof words and a lot of word
salad, and I think it kind ofmakes sense why people with
Medicare are confused by theprogram and what is required to
enroll.
Rob Lott (08:41):
Okay. Well, against this backdrop, why don't you
tell us about your paper? I knowyou looked at the Quimby model.
What variables did you measureand what did you find?
J. Wyatt Koma (08:51):
Yeah, so we assessed take up of the Quimby
Medicare Savings Program usingthe most recent data of the
Medicare Current Beneficiarysurvey from 2016 to 2022. And
since the QMB eligibility groupis the largest and most
expansive in coverage, it'sparticularly of interest to
policymakers. And so that's whywe focused on that eligibility
(09:13):
group in particular. And so inour analysis, we first
identified Medicarebeneficiaries who were likely
eligible for the Quimby programbased on their reported income
and assets. And then among thatgroup, we assessed Quimby
enrollment using administrativeenrollment data from CMS that's
linked to the survey data.
(09:34):
So we then compared who isenrolling and the cost related
barriers to care among eligiblebeneficiaries who were enrolled
versus those who were notenrolled in the program.
Rob Lott (09:46):
Got it. Okay. And what'd you find?
J. Wyatt Koma (09:48):
Yeah. So our first set of findings was really
about the take up rate of theQuimby program. And we found
that roughly two thirds ofpeople who were eligible for the
Quimby group were enrolled in2022. We found that an
additional 17% of low incomepeople who were eligible for the
Quimby program were enrolled insome other program, either a
different Medicare SavingsProgram eligibility group, they
(10:10):
were enrolled in full benefitMedicaid, or they were enrolled
in the Medicare Part D LowIncome Subsidy program by
itself. And then the remaining17%, so one in six eligible, QMB
eligible beneficiaries were notenrolled in any of these
programs in 2022.
And so these people with lowincomes were fully exposed to
(10:31):
Medicare cost sharing andpremiums.
Rob Lott (10:33):
I wanna ask you a little more to look under the
hood there in those findings.But before we do, let's take a
quick break. And we're back. I'mhere with Wyatt Coma talking
(11:38):
about the Qualified MedicareBeneficiary Program. So Wyatt, I
think one of the key findings inthe paper is that there was
actually a slight increase inthe proportion of enrollees in
this program.
And I'm wondering if you can saya little more about how
significant that was and whatyou might attribute that
(12:01):
increase to.
J. Wyatt Koma (12:02):
You're right. We do see a slight uptick in take
up of the Quimby eligibilitygroup over the study timeline
from roughly sixty two percentin 2016 to sixty six percent in
2022. And so we don'tspecifically evaluate what
contributed to these changesover time, but there were a
couple of possible explanations.So for one, most states expanded
(12:26):
Medicaid to low income childlessadults under the ACA expansion
pathway since 2014, and thatincluded nine states during our
study period. And our analysisfinds that people who live in
ACA expansion states are morelikely to enroll in QMP than
those who live in non expansionstates.
Rob Lott (12:43):
Is that sort of a kind of I think they call it the
doormat effect kind of when whenpeople are kind of seeing and
hearing promotions about allkinds of different programs,
they kind of start to do theirown research and figure out what
they're eligible for. Is thatkind of your suspicion? What's
going on there?
J. Wyatt Koma (13:02):
Yeah, it could definitely be a piece of the
welcome mat effect. It's worthnoting though that while these
low income Medicarebeneficiaries aren't eligible
for Medicaid through this ACApathway, having Medicaid
enrollment before they enterMedicare might end up increasing
QMB take up if these enrolleeshave, like you said, a greater
awareness of the availableassistance or if they receive
(13:25):
outreach or support totransition to a Medicare savings
program once they enterMedicare.
Rob Lott (13:31):
Got it. Okay. Any other theories or factors that
you identified as sort ofcontributing to that increase?
J. Wyatt Koma (13:40):
Yeah. So I would say the final reason that we
were thinking through was we dosee the highest QMV take up
rates in our study period from2020 to 2022, which was also
when states halted Medicaidredeterminations during the
COVID-nineteen public healthemergency. And so more work is
needed to really assess if thesetake up rates persist after the
(14:04):
2023 to 2025 Medicaid unwinding.
Rob Lott (14:08):
Okay, great. A good future research question you and
your colleagues to come back to.At this point, I'm wondering if
you can tell us a little bitabout the 2023 rule that came
from CMS aimed at streamliningenrollment in these programs.
What does the rule try toachieve and what's the timeline
(14:31):
at this point forimplementation?
J. Wyatt Koma (14:33):
The 2023 CMS final rule was an attempt by the
Biden administration to reducethese barriers to enrollment
that we're seeing in theMedicare Savings Program for
people with low incomes. And soreally broadly, it does two
things. One, the rule includesrequirements for states that
already automatically enrollsupplemental security income or
(14:55):
SSI recipients into Medicaid tothen also automatically enroll
these SSI recipients into theQMB program by October. And then
two, the rule tries tostreamline eligibility and
enrollment information betweenthe QMB program and the Medicare
Part D Low Income Subsidyprogram, which lowers drug costs
(15:18):
for enrollees. And so morespecifically, the rule tries to
encourage states to aligneligibility criteria between the
Medicare Part D LIS and the QMBQMB program.
And then it requires states touse the income and assets data
from the Part D LIS applicationsin new Medicare Savings Program
(15:39):
applications by April. And sooverall, back to our patchwork
discussions of low incomesupport for Medicare
beneficiaries, this rulebasically tries to streamline
enrollment into the Quimbyprogram and other Medicare
Savings Eligibility Groups withother low income assistance
programs that have a super largeoverlap in the eligible
(16:01):
population. And it kind ofrequires states to auto enroll
or use existing eligibility datawhere possible, which really
could make it easier for peopleto enroll and then also could
reduce costs for state Medicaidprograms.
Rob Lott (16:15):
Got it. Okay, seems like a pretty straightforward
and reasonable attempt atreducing some of that
bureaucratic burden andinefficiency to get people who
are eligible into the system.How might your paper shed some
light on the implementationprocess for this rule. In other
(16:36):
words, is there relevance fromyour findings to the people at
CMS who are charged with puttingthis rule into effect?
J. Wyatt Koma (16:45):
Yep, we definitely hope so. We wrote
this paper to try and informpolicymakers who were trying to
improve enrollment in the QMBprogram. So our findings do a
few things. One, we provide themost recent estimates of QMB
take up and find that while takeup rates have increased, one in
three eligible people have notenrolled. And then two, we
(17:06):
provide some demographiccharacteristics of who is and is
not enrolling in the Quimbyprogram, which hopefully could
inform some targeted outreachstrategies.
And three, our findings supportprior evidence that shows that
the Quimby eligibility groupsreally do help to reduce
financial barriers to care. Andadditionally, these data help to
(17:29):
provide estimates of thepotential impact of the 2023 CMS
final rule. So for example, in2022, six percent of QMB
eligible beneficiaries wereenrolled in full benefit
Medicaid and not enrolled in anyMSP. Under the new rule,
beneficiaries, the six percentof these beneficiaries who
(17:50):
receive SSI would beautomatically enrolled in the
Quimby program in the 35 statesthat automatically enroll SSI
recipients into Medicaid. And wealso found that 3% of QMB
eligible beneficiaries in 2022were enrolled in Medicare Part D
low income subsidy only.
(18:11):
And so the CMS rule encourages,but doesn't require states to
fully align income and assetcounting rules between these two
programs. And so greater stateadoption of the LIS eligibility
rules with the MSP eligibilityrules could facilitate enrolling
a greater share of theseenrollees using data from the
(18:33):
LIS applications. All that saidthough, the current
administration's focus oncutting Medicaid costs could
have a lot of implications forthe future of the CMS rule. CDO
estimates that repealing thesestreamlined enrollment
provisions would result inreductions in enrollment in the
Medicare Savings Program bypotentially millions of
(18:55):
beneficiaries by 02/1934. And soreally these Medicaid
eligibility and enrollmentpolicies need to carefully weigh
the potential impact on lowincome people with Medicare with
any potential cost savings.
Rob Lott (19:08):
Gotcha. You mentioned that CBO estimate. Is that
because there are potential cutsin the Republican reconciliation
package that's moving throughCongress?
J. Wyatt Koma (19:20):
One of the cuts would repeal the 2023 final
rule.
Rob Lott (19:25):
Okay. So before we wrap up, let's take a step back
for our listeners thinking aboutwhere we go from here. What do
you see as the next step interms of policy? And if your
paper were to sort of inspireconcrete specific policy change
going forward in this space,what would that be?
J. Wyatt Koma (19:46):
So I think it's important to first say that
Medicare covers sixty fourmillion older adults and people
with disabilities and that helpsthem access healthcare. But this
coverage can be unaffordable,particularly for those with
modest income and assets. And sothe Medicare Savings Program and
the Quimby Eligibility Group inparticular can really help low
income Americans with Medicareaccess healthcare by making it
(20:08):
more affordable. So in terms ofnext steps for policy, we really
see maintaining the twentytwenty three final rule as a
critical first step tostreamlining enrollment across
these low income programs forMedicare beneficiaries. That
said, we do have some additionalrecommendations as a way to
build on the twenty twenty threefinal rule.
(20:29):
So for example, strongerrequirements for alignment
between the Medicare SavingsProgram eligibility groups and
the Medicare Part D Low IncomeSubsidy could really improve
access to available assistancefor low income beneficiaries and
could reduce administrativecosts for both beneficiaries and
the state Medicaid programs. Butit's important to underscore
(20:49):
that this final rule really onlyimpacts people with Medicaid who
are already enrolled in one ofthe low income programs. And our
analysis finds that nearly onein six of these eligible people
are not enrolled in any of thelow income programs. So
additional outreach andeducation is really needed to
beneficiaries who aren'timpacted by the final rule and
(21:09):
may be the least aware and toface the greatest barriers to
enrolling in the MedicareSavings Program.
Rob Lott (21:15):
Well, that's a great spot perhaps to wrap up. Wyatt
Coma, thank you so much formaking the time to chat with us
today and for sharing yourfindings with us. Thank you
J. Wyatt Koma (21:26):
so much for having me.
Rob Lott (21:27):
To our listeners, if you enjoyed the episode, please
share it with a friend, leave areview, subscribe, and of course
tune in next week. Thanks forlistening. If you enjoyed
today's episode, I hope you'lltell a friend about a health
policy.
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