Medicare Eligibility Maximization

State Medicaid programs often have the potential to increase their Medicare reimbursements for services. However, ensuring that all Medicaid members who are eligible for Medicare actually receive coverage requires resources that many states lack.

UMass Medical School’s Commonwealth Medicine division has those resources and the technical skill to mine Medicare data, find those eligible members, and make the savings materialize. With extensive knowledge of federal processes and data exchanges, our Center for Health Care Financing has developed and implemented innovative, state-specific techniques for increasing Medicare coverage:

  • Enhanced Medicare ID to identify Medicaid members who may also be eligible for Medicare coverage
  • Medicare Buy-In Billing Audit to ensure maximization of cost savings opportunities through third-party liability, Medicare eligibility coordination, and payment accuracy
  • Medicare Appeals for Home Health Services to identify potential Medicare coverage using the Medicare appeals process
  • Special Disability Workload Solutions to resolve inaccurate benefit determinations for people with disabilities and ensure that Medicare pays for the appropriate services

The Center for Health Care Financing also identifies members who are eligible for Social Security Old Age, Survivors, and Disability Insurance (OASDI) benefits. After 24 months with OASDI benefits, individuals become eligible to enroll in Medicare — further adding to the potential for states to save.

Our financing consultants use specific techniques to maximize Medicare eligibility:

  • Profile the state’s Medicaid caseload using algorithms that query state and federal data to identify and target populations that do not have Medicare coverage
  • Interpret federal data, pinpoint issues preventing Medicare enrollment, and resolve enrollment issues with the Centers for Medicare and Medicaid Services and the Social Security Administration
  • Evaluate state processes and identify disconnects between the information listed on the state and federal files; recommend enhancements to resolve gaps