Report to Congressional Committees

United States General Accounting Office 

GAO 

March 2004 MEDICARE SAVINGS 

PROGRAMS 

Results of Social 

Security 

Administration’s 2002 

Outreach to LowIncome Beneficiaries 

GAO-04-363 
www.gao.gov/cgi-bin/getrpt?GAO-04-363.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Kathryn G. 

Allen at (202) 512-7118. 

Highlights of GAO-04-363, a report to 

congressional committees 

March 2004

MEDICARE SAVINGS PROGRAMS

Results of Social Security 

Administration’s 2002 Outreach to LowIncome Beneficiaries 

In response to a statutory requirement, SSA is carrying out an annual 

outreach effort to help increase enrollment in Medicare savings programs. 

This outreach effort consists of mailing letters to potentially eligible lowincome beneficiaries nationwide as well as sharing data with states to assist 

with their supplemental outreach efforts. In 2002, SSA sent 16.4 million 

letters to low-income Medicare beneficiaries whose incomes from Social 

Security and certain other federal sources met the income eligibility criteria 

for Medicare savings programs. The 2002 letters provided eligibility criteria 

for programs in the beneficiary’s home state and urged beneficiaries 

interested in enrolling to call a state telephone number provided. In addition 

to sending these letters, SSA provided states with a data file containing 

information on the beneficiaries to whom it sent letters. In 2003, SSA sent 

another 4.3 million letters to potentially eligible beneficiaries, and indicated 

that it intends to repeat the outreach mailing annually to newly eligible 

beneficiaries and a portion of prior letter recipients. 

Following SSA’s outreach efforts in 2002, GAO estimated that more than 

74,000 additional eligible beneficiaries enrolled in Medicare savings 

programs, 0.5 percent of all 2002 letter recipients, than would have likely 

enrolled without the letter. CMS enrollment data also showed that growth in 

Medicare savings programs enrollment for the year following SSA’s mailing 

was nearly double that for each of the 3 prior years. Of the 74,000 additional 

enrollees, certain states and demographic groups had somewhat larger 

increases in enrollment than other groups. The highest additional 

enrollment increase was in Alabama, where 2.9 percent of letter recipients 

enrolled, followed by Delaware at 2.0 percent. Beneficiaries less than 65 

years old, persons with disabilities, racial and ethnic minorities, and 

residents in southern states also had higher enrollment rates than other 

groups. 

The percentage of letter recipients newly enrolling in Medicare savings 

programs following SSA’s 2002 mailing ranged from 0.3 to 2.9 percent among 

the six states GAO reviewed. The varying effects on enrollment by state 

could be attributable to several factors, including the share of eligible 

beneficiaries enrolled in Medicare savings programs prior to the outreach, 

each state’s ability to handle increased call and application volume, and a 

state’s income and asset limits. Four states GAO reviewed reported 

increases in the numbers of calls received or applications mailed or received 

following the SSA mailing and then decreases after the mailing period ended. 

Each of the states GAO reviewed reported that the state or other 

stakeholders conducted additional outreach during SSA’s 2002 outreach.

SSA generally agreed with GAO’s findings. CMS stated that it did not have 

specific comments on the report. 

To assist low-income beneficiaries 

with their share of premiums and 

other out-of-pocket costs 

associated with Medicare, 

Congress has created four 

Medicare savings programs. 

Historic low enrollment in these 

programs has been attributed to 

several factors, including lack of 

awareness about the programs, and 

cumbersome eligibility 

determination and enrollment 

processes through state Medicaid 

programs. Concerned about this 

low enrollment, Congress passed 

legislation as part of the Medicare, 

Medicaid, and SCHIP Benefits 

Improvement and Protection Act of 

2000 (BIPA) requiring the Social 

Security Administration (SSA) to 

notify low-income Medicare 

beneficiaries of their potential 

eligibility for Medicare savings 

programs. The statute also required 

GAO to study the impact of SSA’s 

outreach effort. GAO examined 

what outreach SSA undertook to 

increase enrollment, how 

enrollment changed following 

SSA’s 2002 outreach, and how 

enrollment changed in selected 

states following SSA’s outreach and

what additional outreach efforts 

these states undertook. 

GAO reviewed information 

obtained from SSA and the Centers 

for Medicare & Medicaid Services 

(CMS), analyzed enrollment data 

provided by SSA and CMS, and 

interviewed officials in and 

obtained data from six selected 

states (Alabama, California, 

Louisiana, New York, Pennsylvania,

and Washington). 
Page i GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Letter 1

Results In Brief 3

Background 5

SSA Is Conducting an Annual Outreach Effort Targeted to LowIncome Medicare Beneficiaries 12

Medicare Savings Program Enrollment Increased by More than 

74,000 Beneficiaries Following the 2002 SSA Mailing 16

Enrollment Increases Varied among Selected States We Reviewed, 

with Several Reporting Increased Calls and Applications 

Concurrent with SSA Mailing 20

Agency and State Comments 25

Appendix I Methodology 28 

Appendix II SSA 2002 Outreach Letter 32 

Appendix III Medicare Savings Program Enrollment following 

2002 SSA Mailing by State 34 

Appendix IV Medicare Savings Program Enrollment following 

2002 SSA Mailing by Demographic Group 36 

Appendix V Comments from the Social Security Administration 38 

Related GAO Products 40 

Tables 

Table 1: Medicare Coverage and Beneficiary Cost Sharing for 2003 6

Table 2: Medicaid and Medicare Savings Programs’ Eligibility 

Criteria and Benefits for Low-Income Medicare 

Beneficiaries, 2003 9

Contents 
Page ii GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Table 3: Enrollment in Medicare Savings Programs by Sample 

Cohort, December 2002 18

Table 4: Medicare Savings Program Enrollment, May 1999 to May 

2003 19

Table 5: Increase in Enrollment following SSA’s Outreach to 

Targeted Population in Six Selected States, December 2002 20

Table 6: Average Monthly Calls and Applications Related to 

Medicare Savings Programs for Four States prior to, 

during, and/or after SSA’s Mailing Outreach, January 2002 

to April 2003 23

Figures 

Figure 1: Medicare Savings Programs Enrollment in Two Sample 

Cohorts of SSA Letter Recipients, June 2002 through 

December 2002 17

Figure 2: Sample 2002 SSA Letter 33

Figure 3: Estimated Percentage Change in Medicare Savings 

Program Enrollment Following 2002 SSA Mailing by State, 

December 2002 35

Figure 4: Estimated Percentage Change in Medicare Savings 

Program Enrollment Following 2002 SSA Mailing by 

Demographic Group, December 2002 37
Page iii GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Abbreviations 

BIPA The Medicare, Medicaid, and SCHIP Benefits Improvement 

 and Protection Act of 2000 

CMS Centers for Medicare & Medicaid Services 

FPL federal poverty level 

MBR Master Beneficiary Record 

QDWI Qualified Disabled and Working Individuals 

QI Qualifying Individuals 

QMB Qualified Medicare Beneficiaries 

SLMB Specified Low-Income Medicare Beneficiaries 

SSA Social Security Administration 

SSI Supplemental Security Income 

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Page 1 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

March 26, 2004 

Congressional Committees 

Medicare provides health insurance coverage for a broad array of services, 

including hospital, physician, home health, and other services, to more 

than 40 million Americans who are elderly, disabled, or have end-stage 

renal disease. Medicare beneficiaries pay a portion of the program’s costs 

through cost-sharing provisions—including premiums, deductibles, and 

coinsurance—that can be difficult to afford for low-income beneficiaries. 

To assist low-income beneficiaries, Congress has created several Medicare 

savings programs that help pay for some or all of Medicare’s cost-sharing 

provisions. There are four Medicare savings programs, each with differing 

income eligibility requirements and levels of benefits—the Qualified 

Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary 

(SLMB), Qualifying Individual (QI), and Qualified Disabled and Working 

Individual (QDWI) programs. To enroll, eligible beneficiaries must have 

incomes and assets within the specific program’s federal ceilings and 

enroll through their state Medicaid program, the joint federal state 

program that covers health care services for certain individuals with low 

incomes and resources. States may have less restrictive income and asset 

requirements that eligible beneficiaries meet to qualify. As of September 

2003, about 6.2 million beneficiaries were enrolled in Medicare savings 

programs. 

We reported in 1999 that 43 percent of beneficiaries eligible for the QMB 

and SLMB programs were not enrolled.1

 More recent studies also have 

reported low enrollment rates.2

 Low program enrollment has been 

attributed to several factors, including a lack of awareness about the 

programs, ineffective outreach, a cumbersome eligibility determination 

 1

U.S. General Accounting Office, Low-Income Medicare Beneficiaries: Further Outreach 

and Administrative Simplification Could Increase Enrollment, GAO/HEHS-99-61, 

(Washington, D.C.: Apr. 9, 1999). 

2

See, for example, Kim Glaun, National Senior Citizens Law Center, Medicaid Programs to 

Assist Low-Income Medicare Beneficiaries: Medicare Savings Programs Case Study 

Findings, prepared for The Kaiser Commission on Medicaid and the Uninsured, December 

2002; and Susan G. Haber et al, RTI International, Evaluation of Qualified Medicare 

Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB) Programs, 

prepared for the Centers for Medicare & Medicaid Services, October 1, 2003. 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

and enrollment process that varies among state Medicaid programs, and 

perceived stigma among some potentially eligible beneficiaries about 

enrolling in a program for low-income people. 

Concerned about low enrollment in Medicare savings programs, Congress 

passed legislation in 2000 requiring the Social Security Administration 

(SSA) to conduct outreach to low-income Medicare beneficiaries to notify 

them of their potential eligibility for Medicare savings programs.3

 SSA 

began notifying beneficiaries in response to the statutory requirement in 

2002. The statute also required us to study the impact of SSA’s outreach.4

As agreed with the committees of jurisdiction, this report addresses the 

following questions: 

• What outreach has SSA undertaken to increase enrollment in Medicare 

savings programs in response to the statutory requirement? 

• How did enrollment in the Medicare savings programs change following 

SSA’s 2002 outreach to potential beneficiaries? 

• How did enrollment in these programs change in selected states following 

SSA’s outreach, and what outreach efforts did these selected states also 

undertake? 

To examine SSA’s response to the statutory requirement for outreach to 

eligible low-income Medicare beneficiaries, we obtained relevant 

documents and interviewed officials from SSA and the Centers for 

Medicare & Medicaid Services (CMS), the federal agency responsible for 

administering the Medicare savings programs. To determine how 

enrollment in Medicare savings programs changed following SSA’s 

outreach, we analyzed records from SSA’s Master Beneficiary Record 

(MBR)—a database that contains the administrative records of Social 

Security beneficiaries, including payments for Medicare premiums—and 

we report the additional enrollment following the 2002 SSA outreach that 

was beyond what would have likely occurred in the absence of SSA’s 

outreach. We estimated the additional enrollment increase following the 

SSA mailing to all letter recipients.5

 We analyzed these enrollment changes 

 3

Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), 

Pub. L. No. 106-554, App. F, § 911(a), 114 Stat. 2763, 2763A-583 (adding section 1144 to the 

Social Security Act; codified at 42 U.S.C. § 1320b-14 (2000)). 

4

BIPA § 911(b), 114 Stat. 2763A-584. 

5

Throughout this report, we refer to all beneficiaries who were included in SSA’s mailing as 

“recipients” because past SSA efforts found that only 1.5 percent of letters were returned as 

undeliverable. 
Page 3 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

at the national level as well as separately for all states6 and several 

demographic groups, such as beneficiaries less than 65 years of age or in 

certain minority groups. Any difference in increased enrollment among 

state or demographic groups that we report was statistically significant at 

a 95 percent confidence level. We also obtained CMS’s national enrollment 

data for the Medicare savings programs and compared enrollment trends 

before and after the SSA outreach. Whereas the SSA MBR data we 

analyzed are specific to those beneficiaries who were sent SSA’s mailing, 

the CMS data also included existing beneficiaries and are not limited to 

the beneficiaries who were sent SSA’s mailing. To assess how SSA’s 

outreach affected enrollment in selected states and what outreach efforts 

these states undertook, we interviewed officials and collected data from 

six states—Alabama, California, Louisiana, New York, Pennsylvania, and 

Washington. We selected these states based on several factors, including 

their different levels of change in overall Medicare savings programs 

enrollment from 2002 to 2003, geographic diversity, relatively large 

populations of Medicare savings programs enrollees, and availability of 

data on their program enrollment. It was beyond the scope of our work to 

examine the effectiveness of any outreach performed by states or CMS 

separately from SSA’s outreach. In conducting our analyses, we obtained 

information from SSA and CMS on reliability checks they made on the 

data and any data limitations provided to us, and concluded that their data 

were sufficiently reliable for our analysis. Appendix I provides more 

detailed information on our methodology. We performed our work from 

February 2003 through March 2004 in accordance with generally accepted 

government auditing standards. 

In response to a statutory requirement in the Medicare, Medicaid, and 

SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), SSA is 

carrying out an annual outreach effort to help increase enrollment in 

Medicare savings programs. This outreach effort consists of mailing letters 

to all low-income Medicare beneficiaries nationwide who were not 

enrolled in Medicare savings programs at the time the letters were sent as 

well as sharing data with states to assist with any state outreach efforts. 

From May through November 2002, SSA sent 16.4 million letters to lowincome Medicare beneficiaries whose incomes from Social Security and 

certain other federal sources met the income eligibility criteria for 

Medicare savings programs. Because SSA does not have complete 

 6

Throughout this report, we include the District of Columbia in our discussion of states. 

Results In Brief 
Page 4 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

information on beneficiaries’ income and assets, however, many of these 

beneficiaries could have had other income or assets that would exceed the 

program’s eligibility criteria, thus reducing the number of eligible 

beneficiaries. The 2002 letters provided eligibility criteria for the Medicare 

savings program in the beneficiary’s home state and urged beneficiaries 

interested in enrolling to call a state telephone number provided. In 

addition to sending these letters, SSA provided states with a data file 

containing information on the beneficiaries to whom it sent letters. From 

June through October 2003, SSA sent 4.3 million letters to potentially 

eligible beneficiaries, including beneficiaries newly eligible for Medicare 

savings programs as well as a portion of those who had been sent the 2002 

letter but who had not enrolled. SSA indicated that it intends to annually 

repeat the outreach mailing to potentially eligible beneficiaries. 

Following SSA’s outreach efforts in 2002, we estimated that more than 

74,000 additional eligible beneficiaries enrolled in Medicare savings 

programs than would have likely enrolled without the letter. This 

represents about 0.5 percent of all letter recipients. Further, CMS data 

showed that overall enrollment growth in Medicare savings programs 

nationwide for the year following SSA’s mailing was nearly double each of 

the 3 prior years. Thirty-five states had a statistically significant additional 

increase in enrollment nationwide following the SSA mailing, with the 

largest increases in Alabama (2.9 percent) and Delaware (2.0 percent). 

Beneficiaries less than 65 years old, persons with disabilities, racial and 

ethnic minorities, and residents in southern states had higher additional 

enrollment rates than other groups. 

Additional enrollment in Medicare savings programs varied significantly 

among the six states we reviewed, ranging from 0.3 percent in California, 

Washington, and New York to a high of 2.9 percent in Alabama. The 

varying effects on enrollment by state could be attributable to several 

factors, including the share of eligible beneficiaries already enrolled in 

Medicare savings programs prior to the outreach, a state’s ability to handle 

increased call and application volume, and a state’s income and asset 

limits. Four states we reviewed reported significant increases in the 

numbers of calls received by their hot lines related to Medicare savings 

programs and applications mailed or received during the SSA mailing and 

then decreases after the SSA mailing period ended. Each of the states we 

reviewed reported that the state or other stakeholders, such as community 

organizations that advocate for low-income elderly or private health plans 

that participated in Medicare, supplemented SSA efforts with additional 

outreach that may have also contributed to increased interest and 

enrollment in Medicare savings programs. 
Page 5 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

In commenting on a draft of this report, SSA generally agreed with our 

findings and noted that improvements in state enrollment processes could 

further increase enrollment. CMS stated that it did not have specific 

comments on the report. Louisiana noted that, in comparison to its 

experience in 2002, it observed little increase in calls following the 2003 

SSA mailing. New York noted that it had a larger increase in Medicare 

savings program enrollment overall than we showed in the draft report. 

However, we report the increase in enrollment specifically attributable to 

the 2002 SSA outreach mailing, not the net increase in enrollment, which 

could also be due to factors besides the SSA mailing. 

Medicare covers about 40 million elderly (over 65 years old) and disabled 

beneficiaries. Individuals who are eligible for Medicare automatically 

receive Hospital Insurance, known as part A, which helps pay for inpatient 

hospital, skilled nursing facility, hospice, and certain home health services. 

A beneficiary generally pays no premium for this coverage unless the 

beneficiary or spouse has worked fewer than 40 quarters in his or her 

lifetime, but the beneficiary is liable for required deductibles, coinsurance, 

and copayment amounts. Medicare-eligible beneficiaries may elect to 

purchase Supplementary Medical Insurance, known as part B, which helps 

pay for certain physician, outpatient hospital, laboratory, and other 

services. Beneficiaries must pay a premium for part B coverage, which 

was $58.70 per month in 2003.7

 Beneficiaries are also responsible for part 

B deductibles, coinsurance, and copayments. Table 1 summarizes the 

benefits covered and cost-sharing requirements for Medicare part A and 

part B. 

 7

The premium amount is adjusted each year so that expected Medicare premium revenues 

equal 25 percent of expected Medicare part B spending. 42 U.S.C. § 1395r(a) (2000). 

Background 
Page 6 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Table 1: Medicare Coverage and Beneficiary Cost Sharing for 2003 

Part A – Hospital insurance Beneficiary pays

Part A premium No premium if beneficiary or spouse worked at least 

 40 quarters in lifetime 

Premium if beneficiary or spouse worked fewer than 

 40 quarters in lifetime 

Inpatient hospital $840 deductible per benefit perioda 

$210 copayment per day for days 61-90 

$420 copayment per day for days 91-150b 

All costs beyond 150 days 

Skilled nursing facilityc Nothing for first 20 days 

Up to $105 copayment or less per day for days 21-100

All costs beyond 100 days in the benefit period 

Home healthd No cost sharing 

20 percent coinsurance for durable medical equipment

Hospice Up to $5 copayment for outpatient drugs 

5 percent coinsurance for inpatient respite care 

Blood Cost of first 3 pints 

Part B – Medical insurancee

Part B premium $58.70 per month 

Physician and medical $100 deductible each year 

20 percent coinsurance for most services 

50 percent coinsurance for outpatient mental health 

 services 

Clinical laboratory No cost sharing 

Home healthd No cost sharing 

20 percent coinsurance for durable medical equipment

Outpatient hospital Coinsurance may vary by service and may exceed 50 

 percent 

Blood Cost of first 3 pints 

20 percent coinsurance for additional pints 

Source: CMS. 

a

No deductible is charged for second and subsequent hospital admissions if they occur within 60 days 

of the beneficiary’s most recent covered inpatient stay. 

b

After the first 90 days of inpatient care, Medicare will help pay for an additional 60 days of inpatient 

care (days 91–150). Each beneficiary is entitled to a lifetime reserve of 60 days of inpatient coverage. 

Each reserve day may be used only once in a beneficiary’s lifetime. 

c

To qualify, a Medicare beneficiary must require daily skilled nursing or rehabilitative therapy services, 

generally within 30 days of a hospital stay of at least 3 days in length, and must be admitted to the 

nursing home for a condition related to the hospitalization. 

d

To qualify for services, beneficiaries must be confined to their homes; have a plan of care signed by 

a physician; and need intermittent skilled nursing care (other than solely venipuncture for the purpose 

of obtaining a blood sample), physical therapy, speech-language pathology services, or have a 

continuing need for occupational therapy services. 
Page 7 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

e

No cost sharing is required for certain preventive services, including specific screening tests for 

colon, cervical, and prostate cancer, and flu and pneumonia vaccines. 

Many low-income Medicare beneficiaries who cannot afford to pay 

Medicare’s cost-sharing requirements receive assistance from Medicaid. 

For Medicare beneficiaries qualifying for full Medicaid benefits, state 

Medicaid programs pay for Medicare’s part A (if applicable) and part B 

cost-sharing requirements up to the Medicaid payment rate as well as for 

services that are not generally covered by Medicare, such as prescription 

drugs.8

 To qualify for full Medicaid benefits, beneficiaries must meet their 

state’s eligibility criteria, which include income and asset requirements 

that vary by state.9

 In most states, beneficiaries that qualify for 

Supplemental Security Income (SSI) automatically qualify for full 

Medicaid benefits.10 Other beneficiaries may qualify through one of several 

optional eligibility categories targeted to low-income beneficiaries, 

individuals with high medical costs, or those receiving care at home or in 

the community who otherwise would have been institutionalized. 

To assist low-income Medicare beneficiaries with their premium and costsharing obligations, Congress established several Medicare savings 

programs—the QMB, SLMB, QI, and QDWI programs. Under these 

programs, state Medicaid programs pay enrolled beneficiaries’ Medicare 

premiums. As a result, for QMB, SLMB and QI beneficiaries, Medicare part 

B premiums would not be deducted from their monthly SSA checks. The 

QMB program also pays Medicare deductibles and other cost-sharing 

requirements, thereby saving beneficiaries from having to make such 

payments. Beneficiaries eligible for Medicare savings programs can apply 

 8

Within broad federal guidelines, states have considerable flexibility in how they administer 

their Medicaid programs. States administer covered services under a state Medicaid plan 

that CMS approves. State Medicaid programs must cover certain mandatory services, such 

as physician services and nursing facility care. While Medicare covers some or all of up to 

100 days of skilled nursing facility care following a hospitalization, Medicaid covers 

extended nursing facility care. State Medicaid programs may also cover certain CMS 

approved optional Medicaid services, such as prescription drugs. The federal government 

shares the cost of state Medicaid expenditures according to a statutory formula, whereby 

the federal share ranged from 50 to 77 percent of state Medicaid expenditures in fiscal year 

2003. 

9

Section 1902(r)(2) of the Medicaid statute provides states flexibility to use less restrictive 

or liberalized methodologies than are typically used for Medicaid in counting applicants’ 

income and resources to expand eligibility for the Medicare savings program. 

10SSI provides cash assistance to aged, blind, and disabled individuals who have limited 

income and resources. In 2003, the resource limit was $2,000 for individuals and $3,000 for 

couples. SSI resource limits typically exclude the beneficiary’s automobile and house. 
Page 8 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

for and be determined to be eligible through their state Medicaid 

programs. Thirty-three states have agreements with SSA whereby SSA 

makes eligibility determinations for a state if beneficiaries are deemed 

eligible by SSA to receive SSI benefits.11 In the other 18 states, even if an 

individual is eligible to receive SSI benefits, an individual must file an 

application with the state or local Medicaid agency to be eligible. 

Beneficiaries qualifying for Medicare savings programs receive different 

levels of assistance depending on their income. See table 2 for eligibility 

criteria and benefits for each program. 

 11These agreements are made under authority contained in 42 U.S.C. § 1383c(a) (2000). 
Page 9 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Table 2: Medicaid and Medicare Savings Programs’ Eligibility Criteria and Benefits 

for Low-Income Medicare Beneficiaries, 2003 

Program Income eligibility criteriaa,b Benefits 

Medicaid Low-income Medicare 

beneficiaries, as defined by 

each state, whose incomes 

are up to 100 percent of the 

federal poverty level 

Optional benefits vary by 

state, but typically include 

Medicare part B premiums 

and Medicaid services, 

including those not covered 

under Medicare 

Medicare savings programs 

Qualified Medicare 

Beneficiary (QMB) 

Medicare beneficiaries 

whose incomes are at 100 

percent or less of the federal 

poverty level 

Medicare part Ac (if 

applicable) and B 

premiums, deductibles, and 

coinsurance paid by state 

Medicaid program 

Specified Low-Income 

Medicare Beneficiary 

SLMB) 

Medicare beneficiaries 

whose incomes are above 

100 percent but less than 

120 percent of the federal 

poverty level 

Medicare part B premiums 

paid by state Medicaid 

program 

Qualifying Individuals (QI)d Medicare beneficiaries 

whose incomes are at 120 

percent but less than 135 

percent of the federal 

poverty level 

Medicare part B premiums 

paid by state Medicaid 

program 

Qualified Disabled and 

Working Individuals 

(QDWI)e

Disabled and working 

Medicare beneficiaries 

whose incomes do not 

exceed 200 percent of the 

federal poverty level 

Medicare part A premiums 

paid by state Medicaid 

program 

Source: CMS. 

a

In 2003, the federal poverty level (FPL) per month was $748 for individuals and $1,010 for couples in 

the 48 contiguous states and the District of Columbia. Higher amounts were specified for Alaska and 

Hawaii. 

b

States also have asset limits for individuals to qualify for Medicaid or Medicare savings programs. 

These vary by state, but most often for Medicaid, eligible beneficiaries must have assets no greater 

than the limit for SSI, which is $2,000 for individuals and $3,000 for married couples. SSI resource 

limits typically exclude the beneficiary’s automobile and house. For Medicare savings programs, 

eligible beneficiaries typically must have assets no greater than twice the limit for SSI. 

c

Medicare part A premiums are covered under the QMB program for beneficiaries who worked fewer 

than 40 quarters. 

d

Until December 2002, the QI program, a federal block grant to the states, consisted of two parts—QI1 and QI-2. The QI-1 program (covering beneficiaries with incomes at least 120 percent but less than 

135 percent of FPL) and the QI-2 program (covering beneficiaries with incomes at least 135 percent 

but less than 175 percent of FPL) were originally authorized through December 2002. The QI-2 

program ended as originally provided, but the QI-1 program was reauthorized through September 

2004. 
Page 10 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

e

These individuals are required to pay part A premiums because they are no longer entitled to free 

Medicare part A benefits having successfully returned to work and exhausted the free Medicare part 

A benefits available to them following the end of their disability benefits. 

In 1998, Congress passed legislation specifically providing funding for SSA 

to evaluate ways to promote Medicare savings programs.12 In response, 

SSA conducted demonstration projects to explore the effects of using 

various approaches to increase participation in Medicare savings 

programs. In one of these demonstrations conducted in 1999 and 2000, 

SSA tested six models designed to increase awareness and reduce barriers 

to enrollment. The models were implemented at 20 sites in 10 states, as 

well as the entire state of Massachusetts. The models differed in the extent 

to which SSA was involved in outreach efforts beyond mailing the letters. 

For example, in the “application model,” SSA staff screened beneficiaries 

if they appeared to be eligible, completed applications, collected 

supporting documents, and forwarded the completed application form and 

supporting evidence to the state Medicaid agency for an eligibility 

determination. In the “peer assistance model,” Medicare beneficiaries 

contacted an AARP toll-free number and were screened for program 

eligibility by an AARP volunteer.13 Across all six models, SSA sent more 

than 700,000 letters informing low-income Medicare beneficiaries that they 

may be eligible for benefits under the Medicare savings programs. The 

enrollment rate for each model varied—ranging from an additional 7 

enrollees per 1,000 letters to 26 enrollees per 1,000 letters—with the 

application model recording the highest enrollment rate and peer 

assistance recording the lowest.14

In 2000, Congress amended the Social Security Act, through BIPA, 

requiring the Commissioner of Social Security to notify eligible Medicare 

beneficiaries about assistance available from state Medicaid programs to 

help pay Medicare premiums and cost sharing. BIPA also required SSA to 

furnish each state Medicaid program with the names and addresses of 

individuals residing in the state that SSA determines may be eligible for 

 12Omnibus Consolidated and Emergency Supplemental Appropriations Act, 1999, Pub. L. 

No. 105-277, 112 Stat. 2681, 2681-383 (1998). 

13AARP, formerly known as the American Association for Retired People, is an association 

representing individuals over the age of 50. 

14For further information on the six models and the demonstration project results, see Lisa 

Maria B. Alecxih et al, Results from the SSA Buy-In Demonstration: Final Report, 

prepared by The Lewin Group SSA, October 4, 2001. 
Page 11 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

the Medicare savings programs. SSA is required to update such 

information at least annually.15

In addition to SSA’s outreach efforts, CMS and individual states have 

engaged in efforts to increase enrollment in Medicare savings programs. 

Since fiscal year 2002, CMS has included increasing awareness of the 

Medicare savings programs as one of its Government Performance and 

Results Act (GPRA) goals.16 Specifically, CMS’s goal in fiscal year 2002 was 

to develop a baseline to measure awareness of Medicare savings programs 

and to set future targets for increasing awareness. CMS estimated that 11 

percent of beneficiaries were aware of Medicare savings programs in 2002 

and the goal was to increase this to 13 percent for fiscal year 2003. As part 

of its efforts to increase awareness, CMS has coordinated with states, SSA, 

and other organizations regarding various outreach efforts; provided 

information about Medicare savings programs in various CMS 

publications; and developed a variety of educational materials for targeted 

populations, including minorities. CMS efforts in increasing enrollment in 

earlier years included setting state-specific enrollment targets and 

measuring progress toward these enrollment targets; developing and 

disseminating training and outreach materials to the states, and 

sponsoring national and regional training workshops for a variety of 

stakeholders, including other federal and state agencies, health care 

providers, and community organizations; designing a model application for 

Medicare savings programs that states can consider adopting; and 

providing grant funding to state Medicaid agencies, state health insurance 

assistance programs, and national advocacy groups to test and promote 

innovative approaches to outreach. 

In 2001, CMS also contracted for a survey of states to identify activities 

undertaken to increase program enrollment and streamline administration 

of these programs. Some of the most common state efforts included 

allowing application by mail (49 states), eliminating in-person interviews 

(46 states), developing a shorter application form (43 states), and 

conducting outreach presentations at health fairs (34 states). Other state 

efforts identified by the survey included 

 1542 U.S.C. § 1320b-14(b) (2000). 

16See CMS, FY 2004 GPRA Annual Performance Plan (Washington, D.C., 2003). 
Page 12 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

• increasing awareness of the programs through outreach efforts such as 

direct mailings and other printed material, and public service 

announcements on radio, television, and in newspapers; 

• providing training for employees and education for beneficiaries; 

• developing partnerships with other entities, such as State Health Insurance 

Assistance programs and local agencies on aging, to enhance outreach 

efforts and promote issues and solutions involving the Medicare savings 

programs; 

• eliminating potential barriers to enrollment such as streamlining the 

enrollment and renewal process and easing financial eligibility rules; 

• supplementing program benefits with other benefits, such as prescription 

drug discount programs; and 

• providing information targeting underserved populations, including 

minorities. 

In response to BIPA, SSA is conducting an annual outreach effort to help 

increase enrollment in Medicare savings programs. This outreach consists 

of a nationwide mailing campaign and data sharing with the states. SSA 

selected low-income Medicare beneficiaries to be sent an outreach letter if 

their incomes were below the income eligibility ceilings for the Medicare 

savings programs. From May through November 2002, SSA sent a total of 

16.4 million outreach letters to persons potentially eligible for QMB, 

SLMB, and QI. Additionally, in late 2002, SSA sent about 53,000 letters to 

those potentially eligible for benefits under the QDWI program. Starting in 

2003, SSA has targeted annual outreach letters to individuals newly eligible 

for Medicare as well as a subset of those who were sent outreach letters in 

2002 but are still not enrolled. From June through October 2003, SSA sent 

outreach letters to 4.3 million of these beneficiaries. SSA intends to 

continue its outreach mailing annually to potentially eligible beneficiaries, 

including recipients who did not enroll after receiving earlier letters, as 

well as those whose income has declined, making them eligible for the 

program. In addition to sending outreach letters, in 2002 and 2003 SSA 

provided states with a data file that listed residents who were potentially 

eligible for benefits under the Medicare savings programs. SSA plans to 

continue sharing these data once a year with states. The data provided by 

SSA could be used by the states to coordinate their outreach with SSA’s or 

supplement SSA’s outreach efforts. 

For the 2002 mailing, SSA sent letters three times each week from May 

through November. Each time letters were mailed, SSA sent them to 

approximately 207,000 Medicare beneficiaries randomly selected from the 

16.4 million beneficiaries who were identified as potentially eligible for 

SSA Is Conducting an 

Annual Outreach 

Effort Targeted to 

Low-Income Medicare 

Beneficiaries 
Page 13 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

QMB, SLMB, and QI.17 Letters were targeted to beneficiaries whose 

incomes from Social Security and certain other federal sources were less 

than 135 percent of the federal poverty level (FPL).18 Specifically, those 

selected to be sent the outreach letters were intended to meet the 

following three criteria: 

• individuals and couples entitled to Medicare, or within 2 months of 

Medicare entitlement eligibility; 

• individuals who were not currently receiving Medicare savings program 

benefits under a state Medicaid program or not already entitled to full 

Medicaid based on SSI participation; and 

• individuals and couples whose combined Social Security income and 

Department of Veterans Affairs and federal civil service pensions fell 

below the program’s income eligibility ceiling. 

The letters provided information in English or Spanish about the Medicare 

savings programs, including state-specific asset guidelines and a state 

contact number.19 (See app. II for a sample 2002 outreach letter.) At the 

end of November 2002, SSA sent a separate mailing to about 53,000 

disabled working adults who were potentially eligible for benefits under 

the QDWI program.20

Medicare beneficiaries who had sources of income other than Social 

Security—such as income from employment and public and private 

pensions—and whose incomes were above the programs’ eligibility 

thresholds were selected nonetheless to be sent the SSA outreach letter 

because SSA’s data systems do not collect information on these income 

 17SSA officials stated that the mailings were based on the last two digits of the recipients’ 

Social Security numbers, which are random and not based on any geographic, age, or other 

demographic characteristic. For each mailing, SSA’s mail vendor selected approximately 

207,000 letters based on this sequence, and then sorted the letters by zip code before 

mailing them out. 

18SSA elected to send this mailing only to individuals potentially eligible for the QMB, 

SLMB, and QI-1 programs. SSA did not have current income data needed to select 

potentially eligible QDWI individuals. The FPL for an individual in the 48 contiguous states 

was $8,860 in 2002. For a couple, the FPL was $11,940. The FPL is higher in Alaska and 

Hawaii. 

19Letters were sent in either English or Spanish based on the language preference provided 

to SSA in the past. 

20The QDWI letters were timed by SSA to arrive near the general enrollment period for 

Medicare part A, which runs from January 1 through March 31 each year. 
Page 14 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

sources. In addition, SSA’s records do not contain information about 

beneficiaries’ private assets, making it impossible for SSA to identify 

whether letter recipients had assets within their states’ Medicare savings 

programs’ eligibility limits—typically $4,000 for an individual and $6,000 

for couples. 

In 2002, the Medicare Rights Center, a national health advocacy group for 

older adults and people with disabilities, sought a federal court order 

requiring SSA to resend 1.4 million letters to potentially eligible 

beneficiaries in Connecticut and New York to correct erroneous 

information on the asset limit for the QI program. The New York and 

Connecticut letters had incorrectly informed potential beneficiaries that 

only individuals with assets of less than $4,000 were eligible for the QI 

program, even though Connecticut and New York abolished the asset 

requirement for QI eligibility in 2001 and 2002, respectively. SSA agreed to 

resend the letters and the parties settled the case before trial. 

In addition to sending letters to potentially eligible low-income Medicare 

beneficiaries, in 2002 SSA provided all but six states with an electronic 

data file containing the names of all beneficiaries to whom it had sent 

letters in that state.21 The data file contained information that could assist 

states with outreach efforts, such as the name, address, Social Security 

number, date of birth, spouse’s name, and the basis for Medicare 

entitlement of each letter recipient. SSA is required to provide updated 

data to the states each year.22

For the June through October 2003 mailing, SSA sent a second round of 

letters to about 4.3 million potentially eligible low-income Medicare 

beneficiaries nationwide whom its records indicated might have met the 

QMB, SLMB, and QI income eligibility criteria and were not currently 

enrolled in Medicare savings programs. This mailing included beneficiaries 

who were newly eligible since the 2002 mailing, current Medicare 

beneficiaries who newly met the income criteria,23 and about one-fifth of 

the beneficiaries notified in 2002 who still met the mailing criteria but 

 21SSA’s security protocol requires states to provide certain information in order for SSA to 

send the data files. Six states did not provide this information and therefore SSA did not 

send the data file to them. 

2242 U.S.C. § 1320b-14(b)(1)(B) (2000). 

23For example, individuals who did not previously receive an outreach letter may 

subsequently meet the income criteria due to reduced income from the death of a spouse. 
Page 15 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

were not enrolled in a Medicare savings program.24 At the time we 

conducted our work, enrollment data for beneficiaries who were sent the 

letter in 2003 were not available. 

In contrast to the 2002 letter that provided state-specific eligibility criteria 

and a state-specific telephone number, the 2003 letter did not contain 

customized state information, but provided more general national 

information. The letter suggested that beneficiaries who may be eligible 

check the government list in their local telephone books for their local 

Medicaid contact or call the general 1-800-Medicare number that refers 

callers to state help lines, such as state or local medical assistance offices, 

social services, or welfare offices. SSA gave several reasons for not 

including state-specific information in the 2003 letter. One official 

indicated that there was additional cost to SSA to develop state-specific 

letters and therefore the agency did not tailor the letters for each state. 

CMS officials reported that a few states did not want to provide state-level 

contact numbers because eligibility and other Medicare savings program 

administrative matters were actually conducted at the county levels. 

Furthermore, in some cases, the telephone numbers states initially 

provided were changed shortly before the 2002 mailings were begun, 

creating additional need for SSA to coordinate with states in finalizing the 

letters. However, some state officials we interviewed expressed concern 

about the lack of state-specific information for the 2003 mailing. Their 

concern was that, given that most states had established mechanisms for 

responding to these inquiries for the larger 2002 mailing, not including 

state-specific criteria or contact information on the letter could make the 

letter less effective since it could be more difficult for beneficiaries to 

obtain direct assistance or applications for eligibility determinations. 

 24Thus, over a period of 5 years, SSA will resend letters to all 2002 letter recipients who still 

meet the mailing criteria but have not enrolled in Medicare savings programs. 
Page 16 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

We estimate that SSA’s mailing from May through November 2002 to 16.4 

million potentially eligible beneficiaries contributed to more than 74,000 

additional beneficiaries enrolling in Medicare savings programs. Further, 

in the year following SSA’s mailing, nationwide enrollment in Medicare 

savings programs increased 2.4 to 2.9 percentage points over that in the 3 

previous years. Certain demographic groups also had larger additional 

increases in enrollment following the 2002 SSA mailing. For example, 

beneficiaries less than 65 years old, persons with disabilities,25 racial and 

ethnic minorities, and residents in southern states experienced larger 

additional increases in enrollment. 

On the basis of our analysis of SSA’s Master Beneficiary Record (MBR), 

we estimate that, of the 16.4 million SSA letter recipients in 2002, an 

additional 74,000 beneficiaries (0.5 percent of letter recipients) enrolled in 

Medicare savings programs than would have likely enrolled without the 

mailing. To estimate this increased enrollment, we examined two cohorts 

of letter recipients—a cohort of 1.3 million beneficiaries who were sent 

the letters during the first six mailings in May 2002 and a baseline cohort 

of 1.3 million beneficiaries who were sent the letters during the last six 

mailings through November 2002. Because SSA sent the mailing to 

beneficiaries in a random order nationwide from May through November 

2002, the only difference between the cohorts is the time at which the 

letters were sent to them. As a result, other factors that could influence 

enrollment patterns, such as demographic differences or other outreach 

efforts by CMS and the states, should affect the May and November 

cohorts similarly. We used the November 2002 cohort as a baseline to 

examine how the May 2002 cohort’s enrollment in Medicare savings 

programs was affected following SSA’s mailing. 

As shown in figure 1, by August 2002—3 months after the initial letters 

were sent in May 2002—the Medicare savings program enrollment for the 

May cohort began to increase faster than that of the November cohort, 

which was yet to have the SSA letter sent to them. While the cohorts were 

sent the SSA letters in May or November 2002, SSA officials reported that 

it typically takes about 3 months before enrollment is reported in the MBR. 

 25Persons with disabilities are persons of any age who are unable to do any kind of 

substantial gainful activity because of a physical or mental impairment (or a combination 

of impairments) that has lasted or is expected to last for a continuous period of at least 12 

months, or that is expected to result in death. 42 U.S.C. § 416(i)(1)(A) (2000). 

Medicare Savings 

Program Enrollment 

Increased by More 

than 74,000 

Beneficiaries 

Following the 2002 

SSA Mailing 

More than 74,000 

Additional Beneficiaries 

Enrolled in Medicare 

Savings Programs 

Following SSA’s 2002 

Mailing 
Page 17 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Figure 1: Medicare Savings Programs Enrollment in Two Sample Cohorts of SSA 

Letter Recipients, June 2002 through December 2002 

a

The baseline is the cohort that was sent the letter in November 2002. 

As of December 2002, more than 5,800 additional beneficiaries in the 

cohort of 1.3 million beneficiaries who were sent the letter in May had 

enrolled in Medicare savings programs compared with the November 

cohort, whose enrollment was not yet affected by the mailing.26 (See table 

3.) This additional enrollment in the May cohort represents 0.5 percent of 

the letter recipients. Projecting the experience of the May cohort to the 

universe of the 16.4 million letter recipients results in an estimate of over 

74,000 additional beneficiaries enrolling in Medicare savings programs as a 

result of the 2002 SSA mailing. 

 26After December 2002, additional enrollment among the baseline group began increasing 

faster than the May cohort, indicating that the maximum cumulative effect of the 2002 SSA 

mailing for the May cohort relative to the baseline occurred as of December 2002. 
Page 18 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Table 3: Enrollment in Medicare Savings Programs by Sample Cohort, December 

2002 

Cohort that the 

SSA letter was sent 

to in May 2002 

Baseline 

cohorta

Difference

Number of letter recipients in sample 

cohort who enrolled 30,291 24,473 5,818

Percent of letter recipients who 

enrolled 2.4 1.9 0.5

Estimated total number of recipients 

who enrolled 386,243 311,786 74,457

Source: GAO analysis of SSA MBR data. 

Note: Each cohort included 1.3 million letter recipients. 

a

The baseline represents the cohort that was sent the letter in November 2002 because the effect of 

the letter was not yet evident during the period we analyzed. 

Nationwide, CMS data showed that Medicare savings programs 

experienced an overall net increase in enrollment of 5.9 percent (341,069 

individuals) from May 2002—the start of SSA’s mailing—to May 2003.27

This 5.9 percent increase was nearly double the 3.0 to 3.5 percent 

increases in the 3 previous years before SSA’s nationwide mailings. (See 

table 4.) These data suggest that SSA’s mailing helped to increase 

enrollment at a greater annual rate than in earlier years. 

 27The CMS data showing about a 341,000 increase in Medicare savings program enrollment 

from May 2002 to May 2003 represents the net change in enrollment including both 

increases (due to new enrollees) as well as decreases (due to former program enrollees 

who died or otherwise were no longer enrolled). Our analysis of the SSA MBR data, 

estimating an increase in enrollment following the SSA mailing of about 386,000 

beneficiaries, reflects only new enrollees because the SSA letter went only to those 

beneficiaries not enrolled in Medicare savings programs at the time. 
Page 19 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Table 4: Medicare Savings Program Enrollment, May 1999 to May 2003 

Month/year Enrollment

Annual change in 

enrollment 

Annual percentage 

Increase

May 1999 5,242,378 — —

May 2000 5,398,468 156,090 3.0

May 2001 5,570,231 171,763 3.2

May 2002 5,763,553 193,322 3.5

May 2003 6,104,622 341,069 5.9

Source: GAO analysis of CMS third-party master file. 

Across the United States, letter recipients residing in the southern states 

had a 0.6 percent additional increase in enrollment following SSA’s 

mailing. This was more than residents in the Northeast, Midwest, and 

West, where the additional increase in enrollment was 0.4 percent. Thirtyfive states had an additional increase in enrollment following the SSA 

mailing compared to the increase that would likely have occurred without 

the letter. Of the thirty-five states, the largest additional increase in 

enrollment following the SSA mailing occurred in Alabama, (2.9 percent), 

followed by Delaware (2.0 percent), and Mississippi (1.3 percent). While 

data from 13 other states showed an increase in enrollment following the 

SSA mailing, these increases were not statistically significant. Another 

three states showed a decrease in enrollment following the SSA mailing, 

but these changes also were not statistically significant. Appendix III 

provides the additional percentage change in enrollment following the 

2002 SSA mailing for each state. 

Certain demographic groups also had higher additional increases in 

enrollment rates than the additional increase among all letter recipients. In 

comparison to the 0.5 percent additional increase in enrollment among all 

letter recipients, beneficiaries less than 65 years old and beneficiaries of 

any age who qualified for Medicare as a result of a disability each had a 0.8 

percent additional increase in enrollment following SSA’s outreach.28 Also, 

minority beneficiaries, which based on SSA’s data categories include 

blacks or individuals of African origin, Asians and Pacific Islanders, and 

North American Indians or Eskimos, had a 0.7 percent additional increase 

 28We calculated age as of May 10, 2002, the first date of the SSA mailing, using the 

beneficiary’s date of birth. 

Certain States and 

Demographic Groups Had 

Higher Enrollment Rates 

Following SSA’s Outreach 
Page 20 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

in enrollment. Appendix IV provides data for all demographic groups that 

we examined. 

The percentage of additional letter recipients newly enrolling in Medicare 

savings programs following SSA’s mailings varied significantly among the 

six states we reviewed. Among these six states, enrollment increases 

ranged from 0.3 to 2.9 percent. Further, several states we reviewed 

reported that calls to their telephone hot lines and applications mailed or 

received increased sharply during the period of the SSA outreach. In 

addition, some states supplemented SSA efforts with outreach efforts of 

their own, while other states were aware of or assisted outreach efforts by 

private or community groups. 

Among the states we reviewed, SSA’s outreach had varying effects on the 

percentage of letter recipients enrolling. Alabama, with 2.9 percent 

additional letter recipients enrolled compared to the percentage that likely 

would have enrolled without the SSA letter, had the largest additional 

increase in enrollment following the SSA mailing. This contrasts with the 

national average of 0.5 percent. For the states we reviewed, SSA’s 

outreach had the least impact on Medicare savings program enrollment in 

California, Washington, and New York with a 0.3 percent increase in 

additional enrollment. (See table 5.) 

Table 5: Increase in Enrollment following SSA’s Outreach to Targeted Population in 

Six Selected States, December 2002 

State 

Percentage of additional letter recipients 

enrolling following SSA mailing 

Alabama 2.9

Louisiana 0.9

Pennsylvania 0.4

California 0.3

Washington 0.3

New York 0.3

All States 0.5

Source: GAO analysis of SSA’s Master Beneficiary Record. 

Enrollment Increases 

Varied among 

Selected States We 

Reviewed, with 

Several Reporting 

Increased Calls and 

Applications 

Concurrent with SSA 

Mailing 

SSA Outreach Efforts Had 

Varying Effects on 

Enrollment in Selected 

States 
Page 21 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

The varying effects on enrollment by state can be attributed to several 

factors, including, the share of eligible beneficiaries already enrolled in 

Medicare savings programs prior to the outreach, a state’s ability to handle 

increased phone calls and applications, and a state’s income and asset 

limits. For example, a smaller share of low-income elderly beneficiaries in 

Alabama was enrolled in QMB as of the year prior to the SSA mailing than 

the national average. Specifically, the number of QMB enrollees in 

Alabama in 2001 was about half the number of Alabama seniors reported 

by the Census Bureau to have incomes below the limit for the QMB 

program. In contrast, about three-quarters of the seniors nationwide who 

reported income below the QMB limit were enrolled. As a result, a larger 

number of letter recipients in Alabama may have been able to meet the 

QMB and other Medicare savings program eligibility criteria whereas other 

states may have already enrolled a larger share of these beneficiaries. 

Further, each of the states we reviewed established or used an existing 

state-specific telephone number that was listed in the SSA letter to receive 

calls. After the SSA mailing started, however, California’s phone number 

was discontinued and calls were redirected to CMS’s nationwide 1-800-

Medicare number. California’s lower enrollment could also result from its 

eligibility requirements for SSI. For example, in a prior demonstration, 

SSA’s mailing in 1999 and 2000 resulted in lower enrollment in California 

than in other demonstration sites, in part because the state offered a 

generous state supplement to SSI. Therefore, there were potentially not as 

many people eligible for the Medicare savings programs.29 In addition, 

other state differences, such as different state asset eligibility 

requirements and application requirements as well as state efforts to 

support the SSA outreach, may have contributed to different effects 

among states. 

States we reviewed often reported that calls to their hot lines and 

applications for Medicare savings programs increased significantly during 

the period of the 2002 SSA mailing. Four states provided data on the 

monthly trends in the number of calls either related to Medicare and 

Medicaid in general or the Medicare savings program specifically that 

showed increases concurrent with the 2002 SSA mailing. Three states were 

also able to provide data on changes in the number of applications sent to 

interested beneficiaries or received from beneficiaries. (See table 6.) While 

 29See Lisa Maria B. Alecxih et al, Results from the SSA Buy-In Demonstration: Final 

Report. 

States Reported Increased 

Interest in Medicare 

Savings Programs 

Concurrent with SSA and 

States’ Outreach Efforts 
Page 22 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

officials in several states indicated that not all of the increases noted could 

be attributed directly to the SSA mailing, the data provided by the states 

suggest that beneficiaries’ interest in Medicare savings programs increased 

during the mailing period. For example, Alabama experienced a 19 percent 

increase in monthly calls to its state hot line related to any Medicare and 

Medicaid issue after the SSA mailings began; this was followed by a 25 

percent decrease after the mailings ended. Alabama also experienced a 

158 percent surge in applications received per month during the SSA 

mailing and then a decrease of 57 percent afterwards. State officials 

reported that Washington tracked calls and applications specific to the 

SSA mailing, and these data showed 85 percent decreases in both monthly 

call volume and applications mailed out to beneficiaries after the mailings 

ended; Washington also reported a 72 percent monthly decrease in 

applications received after the 2002 mailings ended. 
Page 23 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Table 6: Average Monthly Calls and Applications Related to Medicare Savings 

Programs for Four States prior to, during, and/or after SSA’s Mailing Outreach, 

January 2002 to April 2003 

State Average monthly calls Average monthly applications 

Alabama Average monthly calls for any 

Medicaid or Medicare issue 

(including Medicare savings 

programs): 

• Prior to: 25,133 

• During: 30,010 (19 percent 

increase) 

• After: 22,485 (25 percent 

decrease) 

Average monthly applications 

received related to Medicare 

(including Medicare savings 

programs): 

• Prior to: 1,474 

• During: 3,802 (158 percent 

increase) 

• After: 1,618 (57 percent decrease)

Louisiana Average monthly calls for 

Medicare savings programs: 

• Prior to: 301 

• During: 1,849 (515 percent 

increase) 

• After: 516 (72 percent 

decrease) 

Average monthly applications mailed 

for Medicare savings programs:a

• Prior to: 53 

• During: 1,571 (2,865 percent 

increase) 

• After: 226 (86 percent decrease) 

 Average monthly applications 

received for Medicare savings 

programs: 

• Prior to: 2,131b

• During: 2,940 (38 percent 

increase) 

• After: 3,634 (24 percent increase 

Pennsylvania Average monthly calls for 

Medicare savings programs: 

• Prior to: 1,095 

• During: 4,418 (303 percent 

increase) 

• After: 2,039 (54 percent 

decrease) 

Not availablec

 

Washington Average monthly calls for 

Medicare savings programs 

specific to the SSA mailing: 

• Prior to: not available 

• During: 1,180 

• After: 175 (85 percent 

decrease) 

Average monthly applications mailed 

to beneficiaries in response to the 

SSA mailing: 

• Prior to: not available 

• During: 1,127 

• After: 168 (85 percent decrease) 
Page 24 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

State Average monthly calls Average monthly applications 

Washington 

(continued) 

 Average monthly applications 

received in response to the SSA 

mailing: 

• Prior to: not available 

• During: 436d

• After: 121 (72 percent decrease) 

Source: GAO analysis of data from selected states. 

Note: Unless otherwise noted, the period prior to the SSA mailing included January through April 

2002; the period during the mailing was May through November 2002; and the period after the 

mailing was December 2002 through April 2003. 

a

Louisiana provided data on the number of applications that were sent to beneficiaries from the state’s 

Medicaid office. These averages do not include applications mailed by other agencies or 

organizations across the state, which may explain why more applications were received than mailed 

during the same period. 

b

We did not include January 2002 applications in the monthly average because of a large surge in 

applications during that month, which was probably attributable to the state’s QI program temporarily 

closing and reopening for enrollment. 

c

Pennsylvania reported that about 0.5 percent of individuals sent the SSA mailing filed applications, 

and 73 percent of filed applications were approved, but the officials could not provide monthly data. 

d

Data on applications received were not available for May and June 2002 and are not included in the 

average. 

Concurrent with SSA’s mailing, each of the states we reviewed reported 

that the state or other stakeholders conducted additional outreach. For 

example, the Louisiana Department of Health and Hospitals and the 

Pennsylvania Health Law Project, a coalition advocating for low-income 

individuals and the disabled, each received 3-year grants from the Robert 

Wood Johnson Foundation in 2002 to conduct outreach to low-income 

Medicare beneficiaries in these states. A state official also reported that in 

2002 the New York Department of Health developed and distributed 

100,000 copies of a brochure called “How To Protect Your Health and 

Money,” which included information about the Medicare savings 

programs, and conducted a “Senior Day” at 16 sites in New York City and 

several other districts as well as presentations at local fairs. Other states 

reported coordinating with community or state organizations as well as 

private health plans participating in Medicare, such as health maintenance 

organizations participating in the Medicare + Choice program.30 Some 

private health plans conducted outreach to increase Medicare savings 

program enrollment since CMS pays these plans a higher rate for these 

 30California officials also reported that Medicare health maintenance organizations in 

California provided outreach through private contractors approved by CMS. 
Page 25 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

enrollees. Several state officials also said that their states work with other 

groups, such as the local departments of aging or senior services and local 

businesses and community organizations, to assist with outreach efforts to 

potentially eligible beneficiaries. None of the states we reviewed reported 

having assessed the effectiveness of their outreach efforts. 

Of the six states we reviewed, only Louisiana and Pennsylvania officials 

reported that they used the data file listing names and addresses of 

potentially eligible beneficiaries provided by SSA in 2002 to assist with 

state outreach or enrollment efforts. For example, after receiving the SSA 

data file, seven parishes in Louisiana used it to obtain a list of potentially 

eligible beneficiaries and sent an application with a letter and return 

envelope to these beneficiaries. In 2003, about 20,450 applications were 

mailed to potential beneficiaries. Pennsylvania officials used the file to 

cross-check against the state’s own data system to assess the number of 

applications authorized, rejected, or denied as a result of the SSA mailing. 

We provided a draft of this report to SSA, CMS, and state Medicaid 

agencies in Alabama, California, Louisiana, New York, Pennsylvania, and 

Washington. In written comments, SSA generally concurred with our 

findings and provided technical comments that we incorporated as 

appropriate. SSA also noted that improvements in state enrollment 

processes could further increase enrollment. SSA’s comments are 

reprinted in appendix V. In a written response, CMS stated it did not have 

any specific comments on the report. However, CMS provided technical 

comments that we incorporated as appropriate. 

While we did not examine the effects of SSA’s 2003 mailing, Louisiana 

Medicaid officials indicated that, in comparison to the 2002 SSA mailing, 

there was little increase in call volume following SSA’s 2003 mailing, and 

that they believe that this was because a state-specific telephone number 

was not included in the 2003 outreach letter. New York Medicaid officials 

stated that they found an increase in Medicare savings program enrollment 

of over 6 percent from December 2002 to December 2003. However, in 

addition to being a different timeframe from what we examined, we do not 

believe that all of this increase can be attributed to the SSA mailing. Based 

on our analysis of SSA’s MBR data, we report a 0.3 percent increase in 

enrollment in New York specifically attributable to the 2002 SSA outreach 

mailing. We found the net increase in enrollment from May 2002 to May 

2003 (following SSA’s 2002 mailing) to be 5.9 percent nationwide, similar 

to the net increase in enrollment that New York reported from December 

2002 to December 2003. Louisiana and Pennsylvania Medicaid officials 

Agency and State 

Comments 
Page 26 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

also provided technical comments that we incorporated as appropriate. 

Alabama, California, and Washington Medicaid officials reviewed the draft 

and stated that the report accurately reflected information relevant to their 

respective states. 

We are sending copies of this report to the Commissioner of SSA, the 

Administrator of CMS, and other interested parties. We will also provide 

copies to others on request. In addition, this report will be available at no 

charge on GAO’s Web site at http://www.gao.gov.

Please call me at (202) 512-7118 or John Dicken at (202) 512-7043 if you 

have any additional questions. N. Rotimi Adebonojo and Rashmi Agarwal 

were major contributors to this report. 

Kathryn G. Allen 

Director, Health Care—Medicaid 

 and Private Health Insurance Issues 
Page 27 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

List of Committees 

The Honorable Charles E. Grassley 

Chairman 

The Honorable Max Baucus 

Ranking Minority Member 

Committee on Finance 

United States Senate 

The Honorable Joe Barton 

Chairman 

The Honorable John D. Dingell 

Ranking Minority Member 

Committee on Energy and Commerce 

House of Representatives 

The Honorable William M. Thomas 

Chairman 

The Honorable Charles B. Rangel 

Ranking Minority Member 

Committee on Ways and Means 

House of Representatives 
Appendix I: Methodology 

Page 28 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

To determine what outreach the Social Security Administration (SSA) 

conducted in response to the statutory requirement, we obtained and 

reviewed copies of SSA documents, including sample 2002 and 2003 

outreach letters and data on the number of letters sent to eligible Medicare 

beneficiaries in each state, as well as reports prepared by the Centers for 

Medicare & Medicaid Services (CMS) related to the Medicare savings 

program. In addition, we interviewed officials from the SSA and CMS. 

To determine how enrollment changed following SSA’s outreach, we 

analyzed records from SSA’s Master Beneficiary Record (MBR)1

—a 

database that contains the administrative records of Social Security 

beneficiaries, including payments for Medicare premiums—and CMS’s 

national enrollment data for the Medicare savings programs. The MBR 

data contain demographic information as well as information on the 

monthly deductions made from beneficiaries’ Social Security checks to 

cover Medicare part B premiums.2

 We obtained MBR data on beneficiaries 

who were sent the outreach letters in the first six mailings in May and the 

last six mailings through November 2002,3

 representing 2.6 million of the 

16.4 million Social Security beneficiaries who were sent letters from SSA. 

To determine which letter recipients enrolled in the Medicare savings 

programs following SSA’s 2002 mailing, we identified letter recipients who 

met the following criteria: 

• those whose date of eligibility for Medicare savings programs began 

January 2002 or afterwards; 

• those for whom a third-party payer, specifically a state, made payments on 

their behalf to cover Medicare part B premiums; 4

 and 

 1

The MBR contains records for Social Security beneficiaries who were entitled to receive 

benefits under the Old-Age, Survivors and Disability Insurance program. SSA provided us 

with certain records from the MBR that included demographic information as well as 

Medicare benefit payments. 

2

For Medicare beneficiaries who elect to participate in Medicare part B, SSA typically 

withholds an amount equal to their Medicare part B premium from their monthly Social 

Security checks. 

3

Mailing dates for the May cohort include those from May 10 through May 22, 2002, and for 

the November cohort include mailing dates from October 28 through November 8, 2002. 

4

MBR data show third-party payments from three sources—a state, a private payer, or 

federal civil service. 

Appendix I: Methodology 
Appendix I: Methodology 

Page 29 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

• those who no longer had the premium deduction made from their Social 

Security checks to cover Medicare part B premiums at any point from June 

2002 through December 2002.5

In order to estimate the impact of the SSA outreach mailing on additional 

enrollment in Medicare savings programs, we analyzed monthly 

enrollment from June 2002 to December 2002 for two cohorts of letter 

recipients to identify letter recipients who enrolled in Medicare savings 

programs following the initiation of the SSA mailing in May 2002.6

 Because 

the mailings were sent to beneficiaries in a random order, the only notable 

difference between the recipients in the two cohorts would be the timing 

of when the SSA letters were sent to them. SSA officials noted that it 

typically takes about 3 months until enrollment is reported on the MBR. 

Therefore, since the mailings began in May 2002, the first effects of the 

mailing would not have been apparent until after June 2002. We analyzed 

the MBR data provided by SSA to determine specifically what month and 

year a letter recipient enrolled in Medicare savings programs. Using the 

enrollment by the November cohort as a baseline because these 

individuals met the same selection criteria as those in the May cohort, we 

estimated the net effect of the SSA mailing by comparing the difference in 

cumulative monthly enrollment between the May and November cohorts 

in December 2002—this difference represented the additional enrollment 

we attributed to the SSA mailing.7

 We made the comparison in December 

2002 because after this date the enrollment of the baseline group began 

increasing at a rate faster than the May cohort, indicating that this was the 

point when the largest cumulative difference in enrollment between the 

two cohorts occurred before the effects of the mailing started becoming 

evident for the November cohort. Using the same methodology, we 

calculated the effect of the SSA outreach letter for certain demographic 

 5

When a Medicare beneficiary enrolls in a Medicare savings program, the Medicare part B 

premium is no longer deducted from the beneficiary’s Social Security check but is instead 

paid by the state. 

6

Our data for both cohorts did not include beneficiaries potentially eligible for QI-2 or the 

53,000 beneficiaries who were sent a November 2002 SSA mailing about potential eligibility 

for the separate QDWI program. 

7

Our analysis may not include potential beneficiaries in the May cohort who significantly 

delayed presenting a Medicare savings program application to state Medicaid offices for 

eligibility screening or those whose applications were in the eligibility determination 

process after December 2002. In addition, some letter recipients in the November cohort 

may have enrolled prior to receiving the letter because they learned about the programs 

from others, such as neighbors or relatives, who already received the mailing. 
Appendix I: Methodology 

Page 30 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

groups and for beneficiaries in each state. We also obtained and analyzed 

data contained in CMS’s third party master file for the period May 1999 to 

May 2003 that tracks national Medicare savings programs enrollment.8

Using these data, we examined how national Medicare savings enrollment 

trends compared before and after the 2002 SSA mailing. 

To determine how additional enrollment in the programs changed in 

selected states following SSA’s outreach and what outreach efforts these 

states undertook, we interviewed Medicaid officials in six states—

Alabama, California, Louisiana, New York, Pennsylvania, and Washington. 

We selected these states based on several factors, including states with 

different levels of change in overall Medicare savings programs enrollment 

from 2002 to 2003, geographic diversity, relatively large populations of 

Medicare savings programs enrollees, and availability of data on program 

enrollment. We also reviewed CMS’s third party master file to identify how 

many beneficiaries in each state were enrolled in Medicare savings 

programs, and analyzed records from SSA’s MBR to estimate the 

additional enrollment in each state following the SSA mailing. In addition, 

we obtained information from each state to the extent available on its 

involvement with the SSA mailing, the state’s specific eligibility criteria for 

its Medicare savings program, outreach efforts conducted by the state to 

low-income Medicare beneficiaries, and state data on call and application 

volume before, during, and after the SSA outreach. 

We obtained information from SSA and CMS on their data reliability 

checks and any known limitations on the data they provided us. SSA and 

CMS perform quality controls, such as data system edits, on the MBR and 

the third party beneficiary master file, respectively. We concluded that 

their data were sufficiently reliable for our analysis. A few MBR variables 

have certain limitations. For example, some Medicare beneficiaries receive 

their Social Security payments electronically, and therefore may not keep 

the record of their mailing address current. For our analysis we only used 

the beneficiary’s state of residence, which is less likely to change as SSA 

reported that, even if a beneficiary’s address changes, the beneficiary often 

 8

The third-party master file contains records for Medicare beneficiaries for whom a third 

party, such as a state welfare agency or a private group payer, pays their Medicare part A or 

B premiums. SSA’s field offices, state welfare agencies, private groups, and the Office of 

Personnel Management collect the information and send it to CMS for monthly updates. 

CMS uses these data to track enrollment and bill states and other groups accordingly. 
Appendix I: Methodology 

Page 31 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

stays within the same state of residence. Finally, since it is optional for 

beneficiaries to identify their race, a number of Social Security recipients 

do not. However, sufficient numbers of individuals reported their race to 

to allow us to analyze these data and also report missing or unknown 

values. 
Appendix II: SSA 2002 Outreach Letter 

Page 32 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

SSA mailed 16.4 million letters in 2002 to potentially eligible Medicare 

beneficiaries notifying them about state Medicare savings programs. These 

letters were customized to include state-specific information, including a 

state contact number. These letters were sent in English or Spanish, 

depending on the beneficiary’s preference. Figure 2 provides a sample of 

the outreach letter sent to a beneficiary in Texas between May and 

November 2002. 

Appendix II: SSA 2002 Outreach Letter 
Appendix II: SSA 2002 Outreach Letter 

Page 33 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Figure 2: Sample 2002 SSA Letter 

Source: SSA.
Appendix III: Medicare Savings Program 

Enrollment following 2002 SSA Mailing by 

State 

Page 34 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Figure 3 shows enrollment by state of the estimated 74,000 additional 

beneficiaries who enrolled in Medicare savings programs following the 

2002 SSA mailing. Because these estimates are based on two cohorts of 

about 1.3 million beneficiaries each that represent a sample of the entire 

population of 16.4 million beneficiaries, we calculated 95 percent 

confidence intervals to reflect the potential for statistical error in 

projecting these estimates from the sample cohorts to the entire 

population. The small sample size in states with smaller populations 

results in larger confidence intervals for the estimates for these states. The 

highest additional increase in enrollment was in Alabama, in which an 

estimated 2.9 percent (with a 95 percent confidence interval of 2.6 percent 

to 3.3 percent) of beneficiaries who were sent the SSA letter enrolled than 

if the mailing had not occurred. In three states (Montana, Utah, and 

Vermont) our analysis showed no additional or slightly negative 

enrollment following the SSA mailing, and because the confidence 

intervals for these and 13 other states overlap the numeric value zero, the 

data do not show a statistically significant change in additional enrollment 

in the Medicare savings programs following the 2002 SSA mailing for these 

states. The other 35 states showed a statistically significant increase in 

additional enrollment in the Medicare savings programs following the 2002 

SSA mailing. 

Appendix III: Medicare Savings Program 

Enrollment following 2002 SSA Mailing by 

State 
Appendix III: Medicare Savings Program 

Enrollment following 2002 SSA Mailing by 

State 

Page 35 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Figure 3: Estimated Percentage Change in Medicare Savings Program Enrollment 

Following 2002 SSA Mailing by State, December 2002 
Appendix IV: Medicare Savings Program 

Enrollment following 2002 SSA Mailing by 

Demographic Group 

Page 36 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

On the basis of our analysis of SSA’s MBR, we estimate that enrollment in 

Medicare savings programs was about 74,000 higher for Medicare 

beneficiaries following the 2002 SSA mailing than it would have been 

without the mailing. This represents about 0.5 percent of the 16.4 million 

letters sent nationwide. However, this additional enrollment following the 

SSA mailing varied among demographic groups. 

Figure 4 shows the additional enrollment in Medicare savings programs 

following the 2002 SSA mailing by geographic region and demographic 

groups, including racial categories, sex, disability status, and age 

categories. Because these estimates are based on two cohorts of about 1.3 

million beneficiaries each that represent a sample of the entire population 

of 16.4 million beneficiaries, we calculated 95 percent confidence intervals 

to reflect the potential for statistical error in projecting these estimates 

from the sample cohorts to the entire population. Additional enrollment 

following the 2002 SSA mailing was statistically significantly higher among 

beneficiaries in southern states compared to other geographic regions, 

minorities compared to white beneficiaries, beneficiaries with disabilities 

compared to beneficiaries without disabilities, and beneficiaries who were 

younger than 65 years compared to those who were 65 years or older. 

Appendix IV: Medicare Savings Program 

Enrollment following 2002 SSA Mailing by 

Demographic Group 
Appendix IV: Medicare Savings Program 

Enrollment following 2002 SSA Mailing by 

Demographic Group 

Page 37 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Figure 4: Estimated Percentage Change in Medicare Savings Program Enrollment 

Following 2002 SSA Mailing by Demographic Group, December 2002 

Note: Some estimates do not show an upper or lower bound because the 95 percent confidence 

interval was the same as the point estimate due to rounding. 

a

Based on SSA’s data categories, “minority” includes blacks or individuals of African origin, Asians 

and Pacific Islanders, and North American Indians or Eskimos. 
Appendix V: Comments from the Social Security Administration 

Page 38 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Appendix V: Comments from the Social 

Security Administration 
Appendix V: Comments from the Social Security Administration 

Page 39 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 
Related GAO Products 

Page 40 GAO-04-363 Outreach to Low-Income Medicare Beneficiaries 

Medicare and Medicaid: Implementing State Demonstrations for Dual 

Eligibles Has Proven Challenging. GAO/HEHS-00-94. Washington, D.C.: 

August 18, 2000. 

Low-Income Medicare Beneficiaries: Further Outreach and 

Administrative Simplification Could Increase Enrollment. GAO/HEHS99-61. Washington, D.C.: April 9, 1999. 

Medicare and Medicaid: Meeting Needs of Dual Eligibles Raises Difficult 

Cost and Care Issues. GAO/T-HEHS-97-119. Washington, D.C.: April 29, 

1997. 

Medicare and Medicaid: Many Eligible People Not Enrolled in Qualified 

Medicare Beneficiary Program. GAO/HEHS-94-52. Washington, D.C.: 

January 20, 1994. 

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