Low-income Medicare Beneficiaries Research Articles

Access to insurance navigation support through the State Health Insurance Assistance Program (SHIP).

Medicare enrollment is complex, particularly for low-income individuals who are dually eligible for Medicare and Medicaid, and the wrong plan choice can adversely impact beneficiaries' out-of-pocket costs and access to providers and medications. The State Health Insurance Assistance Program (SHIP) is a federal program that provides counseling on Medicare coverage, but the degree to which SHIP services are accessible to low-income beneficiaries is unknown. We interviewed SHIP counselors and coordinators to characterize factors affecting access to and quality of SHIP services for low-income beneficiaries. Availability of volunteers was cited as the primary barrier to SHIP services. Topics related to dual eligibility for Medicare and Medicaid were frequently covered in counseling sessions, and staff expressed a desire for more training related to Medicaid and integrated-care programs. Our results suggest that additional counselors and increased training on topics relevant to dually eligible individuals may improve SHIP's ability to provide health insurance-related information to low-income Medicare beneficiaries.

Medicare Part D low-income subsidies expanded in January 2024, but more needs to be done to ensure that eligible beneficiaries enroll.

The Inflation Reduction Act of 2022 extended full low-income subsidies (LIS) to a small group of Medicare Part D recipients with limited assets and incomes between 135% and 150% of the Federal Poverty Level beginning in January 2024. This policy may result in small enrollment gains among beneficiaries eligible for the new benefits, but the biggest problem with the current LIS program is underenrollment across all eligibility groups. Prior research has shown that underenrollment has been a persistent problem since the LIS program began in 2006, yet little has been done to correct the situation. To identify individual-level factors associated with failure to enroll among low-income beneficiaries eligible for both full subsidies and partial subsidies under the LIS program. We used 2019 Medicare Current Beneficiary Survey data for the study. The Medicare Current Beneficiary Survey is uniquely suited for this work because it contains administrative data on LIS enrollment plus extensive survey information on financial resources necessary to establish program eligibility. We conducted descriptive and multivariate analyses to identify factors associated with failure to enroll when eligible for either full or partial subsidies. Explanatory variables included sociodemographic characteristics, economic resources, work status, health variables, and source of prescription coverage (for nonsubsidized beneficiaries). In 2019, 73% of beneficiaries eligible for full subsidies under pre-Inflation Reduction Act LIS provisions were enrolled, compared with only 25% eligible for partial subsidies. The number of those estimated to be eligible for full subsidies but not enrolled (N = 3.9 million) was more than double that of those eligible but not enrolled for partial subsidies (N = 1.5 million). Factors associated with failure to enroll (older age, male sex, White race, married, higher education, higher income and assets, and excellent/very good health status) were similar for both groups. In multivariate analyses, the single strongest predictor of failure to enroll was receipt of income from work (odds ratio = 5.50; P < 0.001). Among the nonenrolled, 64% eligible for full subsidies and 75% eligible for partial subsidies maintained unsubsidized Part D coverage. Significant numbers of low-income Medicare beneficiaries are eligible for Part D subsidies but fail to enroll. Common characteristics distinguishing nonenrollees from enrollees include older age with higher proportions of White individuals, married individuals, higher income and assets, and better overall health. Two promising targets for increasing LIS enrollment are evidence of work income and unsubsidized Part D coverage.

Publicly Reported Quality Performance for Dual-eligible Special Needs Plans, 2010–2019

ABSTRACT As enrollment increases in Dual-eligible Special Needs Plans (D-SNPs) that exclusively enroll low-income Medicare beneficiaries with Medicaid coverage, better evidence is needed about quality of care in these managed care plans. Using 2010–2019 publicly reported Healthcare Effectiveness Data and Information Set (HEDIS) measures, we found that median HEDIS performance scores were usually slightly worse for D-SNPs than the overall MA program with some reductions in quality performance gaps between 2010 and 2019. D-SNPs had more incomplete performance reporting than MA contracts, especially for measures focused on clinical conditions. Medicare Advantage reporting requirements should require greater transparency about performance in D-SNPs.

Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level

Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program's income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries' ability to afford care. To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care. This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022. Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data. This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries. This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

The impact of Medicaid expansion on spending and utilization by older low-income Medicare beneficiaries.

To examine indirect spillover effects of Affordable Care Act (ACA) Medicaid expansions to working-age adults on health care coverage, spending, and utilization by older low-income Medicare beneficiaries. 2010-2018 Health and Retirement Study survey data linked to annual Medicare beneficiary summary files. We estimated individual-level difference-in-differences models of total spending for inpatient, institutional outpatient, physician/professional provider services; inpatient stays, outpatient visits, physician visits; and Medicaid and Part A and B Medicare coverage. We compared changes in outcomes before and after Medicaid expansion in expansion versus nonexpansion states. The sample included low-income respondents aged 69 and older with linked Medicare data, enrolled in full-year traditional Medicare, and residing in the community. ACA Medicaid expansion was associated with a 9.8 percentage point increase in Medicaid coverage (95% CI: 0.020-0.176), a 4.4 percentage point increase in having any institutional outpatient spending (95% CI: 0.005-0.083), and a positive but statistically insignificant 2.4 percentage point change in Part B enrollment (95% CI: -0.003 to 0.050, p = 0.079). ACA Medicaid expansion was associated with more institutional outpatient spending among older low-income Medicare beneficiaries. Increased care costs should be weighed against potential benefits from increased realized access to care.

ASSESSING THE NEW INFLATION REDUCTION ACT’S IMPACT ON EXPANDING MEDICARE PART D LOW-INCOME SUBSIDIES

Abstract The recently enacted Inflation Reduction Act (IRA) of 2022 extends full low-income subsidies (LIS) to Medicare Part D recipients with limited assets and incomes up to 150% of the Federal Poverty level (FPL) beginning in 2024. Under current law, full Part D subsidies (no annual premiums and nominal cost sharing) are available only to those with incomes up to 135% of the FPL. Partial subsidies are available to those with incomes between 135% and 150% of FPL. Increasing the level of benefits to those currently only eligible for partial subsidies has the potential of significantly lowering out-of-pocket medication costs that pose a barrier to adherence for many low-income Medicare beneficiaries, but the outcome of the new policy will depend on how many enroll. Historically, enrollment among those eligible for partial subsidies has hovered around 30%, but the latest data on LIS participation rates are for 2014. We undertook this study to update LIS eligibility and enrollment numbers to 2019, with a particular emphasis on identifying characteristics of beneficiaries who may benefit from the new policy. Using data from the Medicare Current Beneficiary Survey, we determined that 73% of beneficiaries eligible for full subsidies under current law were enrolled, but only 25% eligible for partial subsidies were enrolled. We conclude that while the IRA will raise the overall level of Part D subsidies, it will be important to engage stakeholders and promote outreach to maximize participation in the leadup to implementation.

Consequences of forgoing prescription drug subsidies among low-income Medicare beneficiaries with diabetes.

The objective is to estimate the take-up of the Medicare Part D Low-Income Subsidy (LIS) among Medicare beneficiaries with diabetes and examine differences in out-of-pocket costs and prescription drug use between LIS enrollees and LIS-eligible non-enrollees. The LIS reduces out-of-pocket drug costs for low-income beneficiaries; however, not all LIS-eligible individuals are enrolled. Take-up of the LIS, and consequences of forgoing this benefit among beneficiaries with diabetes, remains unknown. Health and Retirement Study linked to Medicare administrative data from 2008 to 2016. We conducted two analyses among beneficiaries with diabetes. First, we estimated LIS take-up stratified by income (≤100% of the Federal Poverty Level [FPL] and >100% to ≤150% of FPL). Second, to assess the consequences of forgoing the LIS among near-poor beneficiaries (incomes >100% to ≤150% of FPL), we conducted propensity score-weighted regression analyses to compare out-of-pocket costs, the prescription drug use, and cost-related medication non-adherence among LIS enrollees and LIS-eligible non-enrollees. N/A. Among Medicare beneficiaries with diabetes, 68.1% of those with incomes >100% to ≤150% of FPL received the LIS, while 90.3% with incomes ≤100% of FPL received the LIS. Among near-poor beneficiaries, LIS-eligible non-enrollees incurred higher annual out-of-pocket drug spending ($518; 95 [in USD]% CI: $370 [in USD], $667 [in USD]; p < 0.001), filled 7.3 fewer prescriptions for diabetes, hypertension, and hyperlipidemia drugs (95% CI: -11.1, -3.5; p < 0.001), and were 8.9 percentage points more likely to report skipping drugs due to cost (95% CI: 0.3, 18.0; p=0.04), all compared to LIS enrollees. Despite providing substantial financial assistance with prescription drug costs, the LIS is under-utilized among beneficiaries with chronic conditions requiring routine medication use. As policy makers discuss Part D reforms to address rising out-of-pocket drug costs, they should consider strategies to increase participation in existing programs that alleviate cost burdens among low-income Medicare beneficiaries.

Effects of a Medicaid dental coverage "cliff" on dental care access among low-income Medicare beneficiaries.

To evaluate how an abrupt drop-off, or "cliff," in Medicaid dental coverage affects access to dental care among low-income Medicare beneficiaries. Medicaid is an important source of dental insurance for low-income Medicare beneficiaries, but beneficiaries whose incomes slightly exceed eligibility thresholds for Medicaid have fewer affordable options for dental coverage, resulting in a dental coverage cliff above these thresholds. Medicare Current Beneficiary Surveys (MCBS) from 2016 to 2019. We used a regression discontinuity design to evaluate effects of this dental coverage cliff. This study design exploited an abrupt difference in Medicaid coverage above income eligibility thresholds in the Medicaid program for elderly and disabled populations. The study included low-income community-dwelling Medicare beneficiaries surveyed in the MCBS whose incomes, measured in percentage points of the federal poverty level, were within ±75 percentage points of state-specific Medicaid income eligibility thresholds (n=7508 respondent-years, which when weighted represented 26,776,719 beneficiary-years). Medicare beneficiaries whose income exceeded Medicaid eligibility thresholds were 5.0 percentage points more likely to report difficulty accessing dental care due to cost concerns or a lack of insurance than beneficiaries below the thresholds (95% CI: 0.2, 9.8; p=0.04)-a one-third increase over the proportion reporting difficulty below the thresholds (15.0%). A Medicaid dental coverage cliff exacerbates barriers to dental care access among low-income Medicare beneficiaries. Expanding dental coverage for Medicare beneficiaries, particularly those who are ineligible for Medicaid, could alleviate barriers to dental care access that result from the lack of comprehensive dental coverage in Medicare.

Increasing Medicaid's Stagnant Asset Test For People Eligible For Medicare And Medicaid Will Help Vulnerable Seniors.

Low-income Medicare beneficiaries rely on Medicaid for supplemental coverage but must meet income and asset tests to qualify. We examined states' income and asset tests for full-benefit Medicaid during the period 2006-18 and examined how alternative asset tests would affect eligibility for community-dwelling Medicare beneficiaries ages sixty-five and older. Most states have not updated the dollar limit of Medicaid's asset test since 1989, making the asset test increasingly restrictive in inflation-adjusted terms. We estimated that increasing Medicaid's asset limit by the Consumer Price Index, to Medicare Savings Program levels, or to $10,000 for individuals and $20,000 for couples would increase Medicaid eligibility by 1.7percent, 4.4percent, and 7.5percent, respectively. Simplifying Medicaid's asset test to focus only on certain high-value assets would increase eligibility by 20.5percent. Increasing asset limits would lessen restrictions on Medicaid eligibility that arise from stagnant asset tests, broadening eligibility for certain low-income Medicare beneficiaries and allowing them to retain higher, yet still modest, savings.

Does Medicaid coverage of Medicare cost sharing affect physician care for dual-eligible Medicare beneficiaries?

To assess changes in physicians' provision of care to duals (low-income individuals with Medicare and Medicaid) in response to a policy that required Medicaid to fully pay Medicare's cost sharing for office visits with these patients. This policy-a provision of the Affordable Care Act-effectively increased payments for office visits with duals by 0%-20%, depending on the state, in 2013 and 2014. Fee-for-service claims for a 5% random sample of Medicare beneficiaries in 2010-2016. We conducted a difference-in-differences analysis to compare changes in office visits among Qualified Medicare Beneficiaries (QMBs)-the largest subpopulation of duals for whom payment rates were affected by this policy-to changes among other low-income Medicare beneficiaries for whom payment rates were unaffected (pooled across all states). Next, we conducted a triple-differences analysis that compared changes between QMBs and other low-income beneficiaries in 33 states with payment rate increases of approximately 20% to analogous changes in 14 states without payment increases. The study included administrative Medicare enrollment and claims data for QMBs and a comparison group of other low-income Medicare beneficiaries (1914073 beneficiary-years from 2010 to 2016). Nationally, we did not find a differential increase in office visits among QMBs versus other low-income beneficiaries that coincided with this payment change. In the triple-differences analysis, we did not observe a greater increase in visits among QMBs vs other low-income beneficiaries in states where the policy resulted in large (approximately 20%) increases in payment rates vs states where payment rates were unaffected (triple-differences estimate: -0.12 annual visits, 95% CI: -0.28, 0.04; P=0.15). Physicians' provision of care to low-income Medicare beneficiaries may not be responsive to short-run payment changes.

Rural-Urban Disparities In All-Cause Mortality Among Low-Income Medicare Beneficiaries, 2004-17.

There is growing concern about the health of older US adults who live in rural areas, but little is known about how mortality has changed over time for low-income Medicare beneficiaries residing in rural areas compared with their urban counterparts. We evaluated whether all-cause mortality rates changed for rural and urban low-income Medicare beneficiaries dually enrolled in Medicaid, and we studied disparities between these groups. The study cohort included 11,737,006 unique dually enrolled Medicare beneficiaries. Between 2004 and 2017 all-cause mortality declined from 96.6 to 92.7 per 1,000 rural beneficiaries (relative percentage change: -4.0percent). Among urban beneficiaries, declines in mortality were more pronounced (from 86.9 to 72.8 per 1,000 beneficiaries, a relative percentage change of -16.2percent). The gap in mortality between rural and urban beneficiaries increased over time. Rural mortality rates were highest in East North Central states and increased modestly in West North Central states during the study period. Public health and policy efforts are urgently needed to improve the health of low-income older adults living in rural areas.

Effects of Medicare Drug Subsidies on Adherence for Diabetics: Evidence From a Regression Discontinuity Design

Out-of-pocket prescription drug costs are rapidly rising, particularly for insulin, which is a life-saving drug used by 3.1 million diabetics on Medicare. High out-of-pocket costs place an accentuated financial strain on older adults with diabetes, many of whom have low incomes, and may impede medication adherence, leading to poor health outcomes. The Medicare Part D Low-Income Subsidy (LIS) program limits drug co-pays to under $8.50 per prescription and caps out-of-pocket drug costs for lowest-income recipients (<135% Federal Poverty Level, FPL), resulting in pronounced differences in out-of-pocket costs for those with marginally different incomes. Using detailed income data from the Health and Retirement Study linked to Medicare claims (2008-2016), we employed a regression discontinuity (RD) design to isolate the effects of differences in out-of-pocket costs at eligibility thresholds for the LIS. Diabetic beneficiaries whose income exceeded the LIS eligibility threshold had lower Part D spending (-$945/year, p=0.03, n=2,367) and adherence to oral antidiabetic drugs (-8%, p=0.02). We conducted secondary analyses at the eligibility threshold for Medicaid, as individuals whose income exceeds the eligibility limit for Medicaid (100% of FPL in most states) are significantly less likely to receive the LIS. Above the Medicaid eligibility threshold (n=2,295), annual spending on insulin was $395 lower (p=0.002) and proportion of insulin use was 6% lower (p=0.04). These results suggest low-income Medicare beneficiaries who are not shielded from out-of-pocket costs via the LIS are particularly sensitive to drug costs. Policy proposals to limit out-of-pocket costs could improve medication adherence to high-cost drugs for vulnerable beneficiaries.

Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees

Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.

The Relationship Between Take-up of Prescription Drug Subsidies and Medicaid Among Low-Income Medicare Beneficiaries.

The Relationship Between Take-up of Prescription Drug Subsidies and Medicaid Among Low-Income Medicare Beneficiaries.

State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment.

To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment. 2010-2013 Medicare Current Beneficiary Survey. Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies. Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs. Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

Misclassification of Medicaid Participation by Dual Eligibles: Evidence From the Medicare Current Beneficiary Survey.

Previous studies show that survey-based reports of Medicaid participation are measured with error, but no prior study has examined measurement error in an important segment of the Medicaid population-low-income adults enrolled in Medicare. Using the Medicare Current Beneficiary Survey, we examine whether respondent self-reports of Medicaid enrollment match administrative records and present several key findings. First, among low-income Medicare beneficiaries, the false negative rate is 11.5% when the self-report is interpreted as full Medicaid and 3.7% when the self-report is interpreted as full or partial Medicaid. Second, the likelihood of a false negative report is systematically associated with respondent traits. Third, systematic measurement error results in biased coefficient estimates in models of Medicaid participation defined from self-reports, and the bias is more significant when the researcher interprets self-reports as full Medicaid coverage only. Researchers should use caution when interpreting survey reports as pertaining to full Medicaid coverage only.

Association Of State Policies With Medicaid Disenrollment Among Low-Income Medicare Beneficiaries.

For some low-income Medicare beneficiaries, Medicaid provides financial protection against Medicare's out-of-pocket costs, but many Medicare beneficiaries who qualify for Medicaid are not continuously enrolled. We examined Medicaid disenrollment among fee-for-service Medicare beneficiaries and the relationship between disenrollment and state policies. In the period 2012-16, 18.2percent of Medicare beneficiaries who received full or partial Medicaid disenrolled for reasons other than death. More than 50percent of Medicare beneficiaries who remained without Medicaid one year after disenrolling continued to receive low-income subsidies for Medicare Part D coverage with eligibility requirements similar to those of Medicaid. Among Medicare beneficiaries with continuous Part D subsidies, the rate of Medicaid disenrollment was 24percent lower in states that automatically enrolled recipients of the federal Supplemental Security Income program in full Medicaid, 33percent lower in states with more generous provider payment policies, and 37percent lower in states with less restrictive asset limits for partial Medicaid. Policies that make it easier for people to maintain Medicaid eligibility and that enhance access to care in Medicaid via higher provider reimbursements may reduce disenrollment.

\u201cImplications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey\u201d

BackgroundMedicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries.MethodsSingle-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed.ResultsOut of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30).ConclusionThe results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale.

A pharmacy-based referral program to assist low-income Medicare beneficiaries

ObjectivesThe Certified Aging Resource Educated Specialist (C.A.R.E.S.) Program was developed to increase pharmacist awareness of available programs for Medicare patients with limited income and to integrate an efficient referral process into the pharmacy workflow. The objective is to describe the program in terms of pharmacy personnel satisfaction, pharmacy personnel knowledge, and network outcomes including enrollment and referrals. SettingAlabama community pharmacies. Practice descriptionThe C.A.R.E.S. Program, a partnership between the School of Pharmacy and the Alabama Department of Senior Services, has recruited pharmacists, pharmacy technicians, and pharmacy students to participate on a voluntary basis since its launch in 2015. Practice innovationPharmacies with at least one pharmacist who completed the comprehensive training program can enroll in the pharmacy network. Enrolled pharmacies receive a referral kit containing referral cards and prestamped envelopes. Pharmacy personnel identify patients who appear to have limited income or fall into the Medicare coverage gap and refer these patients to local Aging and Disability Resource Centers (ADRCs). ADRC counselors contact and screen referred patients for all available benefits, including the Medicare Savings Program and the Low-Income Subsidy. EvaluationOne hundred seventy-nine pharmacy personnel have completed the 1-hour introductory continuing pharmacy education, with 99 completing the full 3-hour training. Knowledge was assessed before and immediately after training with an online survey and compared using a paired samples t test. ResultsMean knowledge scores increased significantly (P < 0.001). Twenty-nine pharmacies have enrolled in the pharmacy network. As a result of this pharmacy referral system, 130 patients have been screened for subsidy programs by ADRC counselors. ConclusionTo our knowledge, this is the first identifiable program connecting local pharmacies and ADRCs, equipping pharmacists with the knowledge and means to provide long-term solutions for patients. Other states might consider replicating this partnership to develop similar programs to benefit Medicare beneficiaries with limited income.

Abstract WMP91: Worse Outcomes After Ischemic Stroke for Dual-Eligible Medicare-Medicaid Beneficiaries

Background: Medicaid serves as a safety net for low-income Medicare beneficiaries with limited assets. Over 6.7 million Americans aged ≥65y rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about geographic patterns of dual-eligible status and whether dual eligibles have worse post-ischemic stroke outcomes than those with Medicare alone. Methods: We identified fee-for-service Medicare beneficiaries aged ≥65y with a primary discharge diagnosis of ischemic stroke in 2014. Those with ≥1m of Medicaid coverage were considered dual eligible. We fit spatial mixed models with county-specific random intercepts and adjustment for demographics to calculate and map the risk-standardized percentage of beneficiaries with dual eligibility and stroke hospitalization rates. Mixed models and Cox regression were used to evaluate the relationship between dual-eligible status and outcomes up to 1y, adjusting for demographic and clinical factors. Results: At the national level, 12.5% of beneficiaries were dual eligible. The highest rates of dual eligibility were in Maine, Alaska, and the southern half of the US (Figure), whereas the highest rates of stroke hospitalization were concentrated in the central divisions of the South and parts of the Midwest (Pearson’s r=0.469, p&lt;0.001). Among those hospitalized for stroke, 17.5% were dual eligible (n=44,476 dual eligible: mean age 78.3y, 64% female, 36% nonwhite; n=219,426 Medicare only: mean age 78.9y, 51% female, 12% nonwhite). Dual eligibles had greater risk of readmission within 30d and were more likely to die within 6m and 1y when compared with Medicare-only beneficiaries; there was no difference for in-hospital or 30d mortality. Conclusions: Dual-eligible stroke patients had higher short-term readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.