Older Americans are a diverse group, but on the whole they are vulnerable relative to other age groups, particularly in terms of health and financial security. A number of public and private programs provide financial assistance to older low-income seniors, yet sizable proportions of potentially eligible individuals do not participate. The two major barriers to enrollment in public benefit programs among older individuals are lack of knowledge about the programs and the complexity of the application and enrollment processes. Other factors that may affect enrollment are reluctance to provide personal information, or seniors’ calculation that the value of the benefit is not great enough to warrant their participation in a confusing or difficult application process.
A great deal of activity has occurred in the past several years to boost enrollment in benefit programs, particularly in the Medicare Part D Low-Income Subsidy, which became available in 2006, and the Medicare Discount Drug Card, the transitional benefit provided just before the establishment of the Part D program. The Medicare Savings Programs, which pay Medicare Part A and B premiums as well as copayments for some beneficiaries, also have been the focus of public and private campaigns to increase enrollment. A review of the literature and data related to outreach and enrollment suggests that certain policies and practices can help increase participation in benefit programs for low-income older Americans.
Simplify and Align Eligibility Rules and Enrollment Procedures
Older Americans with limited incomes are faced not only with a multiplicity of programs that potentially will provide needed assistance, but also with multiple sets of complex eligibility rules and enrollment procedures that may differ from program to program and state to state. Simpler eligibility rules and procedures can make programs more accessible for seniors. Eliminating resource tests, which greatly complicate the application process for applicants and program staff, would remove a persistent barrier to enrollment.
The alignment of program eligibility rules and enrollment procedures can also reduce confusion for applicants, promote efficiency, and help control administrative costs. Evidence from states shows that program enrollment has increased following efforts to align the State Pharmacy Assistance Program, Medicare Savings Program, and Low-Income Subsidy eligibility rules. Achieving greater standardization, however, is not without challenges. Efforts may be affected by whether federal, state, or local agencies have direct control over various aspects of the eligibility and enrollment processes for different programs. Changes in eligibility criteria will likely have budgetary implications. It may take time to fully implement comparable eligibility policies and practices, but shifting emphasis from preserving current practices to promoting a more consistent approach has great potential.
A Person-Centered Approach
A “person-centered” approach now has the potential to substantially increase enrollment in benefit programs for qualified low-income seniors. To be most effective, the approach must:
- take all of seniors’ needs into account;
- inform them about eligibility for multiple benefits; and
- provide help when needed, ideally one-on-one assistance that is culturally appropriate and provided by a trusted source.
A person-centered approach directly addresses the common barriers to program participation. The fact that seniors often do not apply because they are unfamiliar with the range of available benefits is addressed when all of the benefits for which an individual may qualify are considered rather than just the one they may know about or have inquired about. Substantial evidence shows that low-income seniors often qualify for multiple benefits. For example, almost 38,000 seniors who used BenefitsCheckUp, a Web-based benefit-screening tool, appeared to be eligible for the Food Stamp Program (renamed the Supplemental Nutrition Assistance Program as of October 2008) in 2007. Among that group, the proportions eligible for, but not participating in other major benefit programs such as the Low-Income Home Energy Assistance Program, Low-Income Subsidy, Medicaid, and Medicare Savings Programs were, respectively, 48, 37, 34, and 30 percent. Learning that they are eligible for multiple benefits, which are of higher value collectively than a single benefit, may encourage seniors to apply.
The availability of assistance is essential for individuals who are confused about the application process. Also, applicants may be less wary of providing information about their financial circumstances if someone they trust is available to explain why the information is needed and how it will be used. Community-based organizations play an important role in identifying seniors who may qualify for benefits and assisting with their applications.
Substantial resources are needed to achieve higher enrollment in available programs, but a person-centered approach can help keep administrative costs low. Among a range of community-based projects designed to help seniors apply for benefits, for example, the process of identifying and connecting with potential beneficiaries accounted for about half of application costs, on average. Thus, if individuals can apply for multiple programs at the same time, finding potential program participants can be a one-time expense rather than one incurred repeatedly for separate program-specific outreach efforts. Also, if information about individuals’ financial and other circumstances can be gathered once but used in multiple ways (with the applicant’s consent), the time and expense associated with collecting the same information multiple times can be reduced and program staff will have easier access to information they need to assess eligibility.
Invest in Technology
Technological advancements provide opportunities to reach people who may be eligible for benefits in new ways and to simplify the enrollment process for benefit programs. Electronic screening tools are used by government and independent organizations to help individuals determine whether they may be eligible for benefits. Linking electronic screening tools to program applications saves a step for applicants, and if they are receiving help with the screening process they can also receive immediate help with the application. Electronic systems that not only have the capacity to screen for eligibility, but also to track enrollment outcomes and renewal dates, can be an important tool to help enrollees renew their benefits in a timely manner.
Systems that have the capacity to capture, save, and transmit data allow government agencies and programs to exchange data in a secure manner. Master client lists can be developed so that different programs have access to information that an individual has previously submitted. Data available already in the system can be used to verify information submitted by applicants. Also, the data can be used to identify individuals applying for or participating in one program who may be eligible for other programs as well. Data from BenefitsCheckUp show, for example, that almost two-thirds of individuals who appear eligible for the Medicare Part D subsidy likely qualify for the Medicare Savings Programs as well, though only 15 percent of those who appear to qualify actually receive MSP benefits.
The use of technology to promote enrollment may require an initial investment to establish electronic screening, application, or data sharing systems. Community-based organizations may have to purchase equipment and train staff. Evidence from states, however, shows significant reductions in administrative costs related to processing applications once systems are established. After initial investments, the cost per beneficiary can be low relative to more traditional outreach and enrollment methods.
Provide Support for Ongoing Outreach and Enrollment Activities
The ideal approach to finding and enrolling seniors in benefit programs is to use technology in concert with one-on-one assistance. Recognizing Medicare beneficiaries’ need for assistance as the program has become even more complex. Congress increased funding over the past several years for the State Health Insurance Assistance Programs, which provide personalized counseling and assistance to Medicare beneficiaries and their caregivers. Congress also approved funds in 2008 to establish a National Center for Benefits Outreach and Enrollment. This type of financial support is critical to efforts to promote enrollment. Support will likely be needed for some time to achieve higher rates of participation in benefit programs for older Americans.
Low-income older Americans are a vulnerable group that can gain considerably from participation in public and private benefit programs. Yet sizable proportions of potentially eligible individuals do not participate. The primary reasons are that seniors are not familiar with the programs, or they are discouraged by the complexity of the enrollment process. Eliminating resource tests would ease the process considerably. Another effective approach to promote enrollment is to better align program eligibility rules and practices, but this may take some time to achieve. In the interim, person-centered enrollment, which involves one-on-one assistance to help seniors apply for multiple benefits, has the potential to increase program enrollment significantly.
Technological advancements could greatly increase the capacity of organizations to identify, reach, and enroll potential participants. Investment and ongoing support are needed to increase enrollment for low-income seniors in benefit programs. More systematic study regarding the effectiveness and efficiency of efforts to increase enrollment will help policymakers and practitioners determine how to use limited resources in the optimal manner.