Constructing the Path to Medicare Half A Purchase-In: Methods for Advocates

Introduction

Medicare serves over 66 million folks nationwide, offering protection for hospital, main, and specialty care to older adults 65 and over and other people with disabilities.^[1] For the overwhelming majority of Medicare enrollees, Medicare’s hospital profit – referred to as Half A – doesn’t require a month-to-month premium fee. Nevertheless, roughly 1% of Medicare enrollees by no means paid into Medicare or labored too little to pay in sufficient to qualify. ^[2] Consequently, they’re uninsured for Half A and should pay Half A premiums with the intention to acquire protection.

Whereas 1% could seem a small quantity, the non-public monetary prices are extraordinarily excessive.^[3] The Half A premium in 2024 is as excessive as $505 a month and information reveals that as of 2021, roughly 773,000 older adults owed a cumulative $4.1 billion in Half A premiums.^[4] The populations topic to those premiums are sometimes folks of coloration, older immigrants, or household caregivers who offered care unpaid.

Fortunately, state Medicaid applications pays Half A premiums for older adults with restricted incomes and assets by means of the Certified Medicare Beneficiary (QMB) program. However the course of to enroll in state fee of Half A premiums is sophisticated and utility guidelines fluctuate by state. In all states, older adults should first apply for conditional Half A on the Social Safety Administration (SSA) after which apply for the QMB program at their state or native Medicaid workplace. Including to this complexity, in 14 states referred to as “group payer states,” older adults can solely conditionally enroll in Half A with a premium through the first three months of the 12 months. In distinction, in all different states referred to as “Half A Purchase-In” states, older adults can enroll at any time of the 12 months, eliminating one of many obstacles to acquiring Half A protection.

California is at present one of many 14 group payer states, however will convert to Half A buy-in state beginning January 1, 2025, after a profitable advocacy marketing campaign launched in 2022. Changing to Half A buy-in state has advantages for each people and state budgets, a uncommon alternative to realize two targets whereas preserving funding and assets.

Utilizing classes discovered in California, this difficulty transient is meant to equip advocates in Group Payer states with info and methods to transform their state to a Half A buy-in state. The present group payer states are: Alabama, Arizona, Colorado, Illinois, Kansas, Kentucky, Missouri, Nebraska, New Jersey, New Mexico, South Carolina, Utah, and Virginia. The transient begins with an summary of Medicare Half A, related prices, and the monetary reduction out there by means of Medicaid to pay for Half A premiums. The transient then outlines the numerous benefits of changing to Half A buy-in standing and the methods advocates in group payer states can use to perform this variation.

Medicare Half A Overview

Medicare medical insurance is out there to people 65 and over and likewise to people underneath age 65 who both have been decided disabled by SSA and have obtained incapacity advantages for twenty-four months, or have a prognosis of Finish Stage Renal Illness (ESRD). Medicare enrollment is computerized for people who’re entitled to free Half A and already receiving Social Safety retirement or incapacity advantages. In the meantime, people who haven’t filed for retirement advantages at age 65, people recognized with ESRD, and people who should pay a premium for Half A, need to affirmatively apply for Medicare at SSA and customarily should accomplish that throughout their preliminary enrollment interval or the Normal Enrollment Interval working January 1 by means of March 31^st every year.^[5]

Medicare Half A Premiums and Late Enrollment Penalties

The overwhelming majority of individuals don’t pay a month-to-month premium for Medicare Half A protection, additionally referred to as “free Half A,”^[6] as a result of they, or their partner, paid Social Safety and Medicare taxes whereas employed and amassed the required work credit at no cost Half A, equal to 40 quarters of labor or about 10 years of employment.^[7] Others should pay for Half A (Half A with a premium)^[8] if they don’t qualify at no cost Half A. Individuals who should pay a month-to-month premium for Half A might by no means have paid Social Safety taxes or solely labored part-time and didn’t accrue sufficient work credit to qualify at no cost Half A. In the meantime, there’s all the time a month-to-month premium for Half B.

Individuals who wouldn’t have the requisite work credit usually are not required to enroll in Half A, however at age 65 can select to purchase into Half A by paying the month-to-month premium, which, in 2024, runs from $278 to $505 a month.^[9] Individuals who pay the upper premium of $505 can pay $6,060 out of pocket yearly in Half A premiums alone. Roughly 90% of people that pay for Half A with a premium are chargeable for paying the upper premium quantity.^[10] Many individuals who should pay a Half A premium select to not enroll in Half A once they first change into Medicare eligible due to the excessive month-to-month value. For an individual at 100% Federal Poverty Stage (FPL) ($1,255/month), the very best Half A premium accounts for 40% of their month-to-month revenue. The remaining revenue leaves little for housing prices, utilities, meals or transportation.

But, the choice to forgo Half A enrollment, can result in increased Medicare prices sooner or later for both the person or the state. For individuals who don’t enroll in Half A with a premium when first eligible, Medicare provides a ten% late enrollment penalty to the bottom premium for twice the variety of years that enrollment was delayed, growing the already excessive month-to-month premium.^[11] In 2021, roughly 30,000 folks cumulatively owed a further 16 million {dollars} in Half A late enrollment penalties.^[12]

Older adults who usually are not eligible at no cost Half A can forgo Half A altogether and enroll in Medicare Half B solely. Nevertheless, this leaves them with out well being protection for providers in any other case coated underneath Half A together with inpatient hospital care, in addition to short-term expert nursing facility stays, dwelling well being, surgical procedure, and hospice. Different protection choices exterior of Medicare could also be out there: low-income older adults might acquire hospital protection by means of Medicaid in the event that they qualify; these with increased incomes can enroll in protection by means of the Inexpensive Care Act exchanges also referred to as Market.[13]

Monetary Help: Certified Medicare Beneficiary Program

State Medicaid applications pays the total Half A premium, together with late enrollment penalties, by means of the Certified Medicare Beneficiary Program (QMB). QMB is a kind of Medicare Financial savings Program and is run by the State Medicaid companies.

The QMB program pays for Half A premiums, Half B premiums, and Medicare coinsurance, deductibles, and copayments. QMB is the one Medicaid program that provides fee of Half A premiums. ^[14] To qualify for QMB, people should be entitled to Half A (both free Half A or Half A with a premium^[15] The federally set revenue restrict for a person is 100% FPL – or $1,255 for a person in 2024– and the useful resource restrict is $9,430. States have the choice of accelerating the monetary eligibility, however can not go beneath these federal limits.

QMB Enrollment to Pay for Half A Premiums

The method for enrolling in QMB for fee of Half A premiums is advanced. People should meet the QMB monetary eligibility limits as described above, be entitled to Half A, have Half B, or within the technique of enrolling in Half B.^[16] As a result of QMB requires entitlement to Half A, however low-income people can not afford the excessive Half A premiums, people can enroll in Half A by submitting a “Conditional Half A” utility with SSA, after which submit an utility for QMB enrollment with their state Medicaid company.^[17] With Conditional Half A, people are enrolled in Half A provided that their QMB utility is accredited. If accredited for the QMB program, the state can pay the Half A premium on their behalf. If the QMB utility is denied, Half A enrollment is cancelled and they aren’t chargeable for Half A premiums.

States have two methods they’ll pay for Half A premiums for QMB enrollees: 1) buy-in settlement or 2) group payer association. As detailed beneath, the fee association a state chooses could make the method smoother or additional complicate it and hinder enrollment in Half A.

Half A Purchase-In

“Purchase-in” is the method states use to enroll people into Medicare and pay for Medicare premiums and cost-sharing by means of the Medicaid program.^[18] State buy-in agreements embrace the method for fee of Medicare premiums and value sharing for each Half A and Half B, waiving commonplace Medicare enrollment intervals, and eliminating late enrollment penalties for particular, qualifying teams. All states have buy-in agreements with CMS for the fee of Half B premiums whereas buy-in for Half A premiums is optionally available.^[19] States got the choice so as to add Half A to their buy-in agreements for QMB enrollees in 1990.^[20] As we speak, thirty-six states and Washington D.C. have opted to make use of a buy-in association for Half A.

With Half A buy-in, states can independently enroll eligible people into Half A with a premium and the QMB program year-round. In different phrases, people wouldn’t have to attend to enroll in Medicare through the common enrollment interval. The buy-in settlement waives this requirement. Whether or not an individual should first apply for conditional Half A is determined by the applicant’s Half B enrollment. These already enrolled in Half B don’t want to use for Conditional Half A.^[21] These people can apply for QMB and the state will robotically enroll them into Half A with a premium with their QMB utility and provoke state fee of their Half A premium. If an individual isn’t already enrolled in Half B, they need to submit a conditional Half A utility with SSA first and may accomplish that at any time through the 12 months after which apply for QMB. Beneath a Half A Purchase-In settlement, CMS waives the late enrollment penalties for any QMB enrollee who didn’t enroll throughout their preliminary enrollment interval.^[22]

Half A Group Payer

Within the 14 group payer states, folks making use of for Half A with a premium and QMB navigate extra obstacles within the course of. In contrast to in Half A buy-in states, even when an individual is already enrolled in Half B, they nonetheless have to conditionally enroll in Half A on the SSA workplace in a bunch payer state. Moreover, in Half A buy-in states, people can enroll in Conditional Half A anytime of the 12 months, however an older grownup in a bunch payer state should submit their Conditional Half A utility to SSA through the Medicare Normal Enrollment Interval that runs from January to March every year. Those that miss this three-month window should wait till the following 12 months. Many advocates report folks don’t usually come again once more subsequent 12 months to reapply. And for folks with language wants aside from English, this course of might be much more complicated. The group payer course of requires the bottom revenue older adults to take a further utility step that isn’t needed within the 36 different states and Washington, D.C.

The appliance course of is simplified underneath Half A buy-in in comparison with group payer preparations. Purchase-in eliminates the brief three-month utility window and leads to extra profitable Half A and QMB functions since people don’t want to recollect to reapply the next 12 months or depend on advocates to succeed in out and remind shoppers to reapply, a lot of whom wouldn’t have the capability to take action. As a result of advocates report SSA workers usually present incorrect or conflicting details about the conditional enrollment course of, QMB-eligible enrollees are sometimes turned away and discouraged from making use of for Half A, delaying their QMB enrollment. Moreover, in contrast to underneath buy-in agreements, states should pay late enrollment penalties underneath group payer preparations.^[23]

Half A Enrollment underneath Half A Purchase-In States versus Group Payer States

Half A Purchase-In States

Group Payer States

The Group Payer Association Impacts Folks with Disabilities, Ladies, and Immigrants the Most

Sure populations are extra negatively impacted by a state’s resolution to make use of a bunch payer association reasonably than a buy-in settlement. As a result of free Half A requires roughly ten years of paid work historical past within the U.S., the group with a Half A premium consists of people that, for varied causes, wouldn’t have the required work credit to qualify. This contains folks with disabilities who, because of their incapacity, didn’t work, labored much less, or had been underpaid in sheltered workshops; girls who usually tend to have offered unpaid care for his or her youngsters or kinfolk; and immigrants who emigrated to the U.S. at an older age and didn’t work lengthy sufficient within the U.S. to qualify. Information reveals that nationwide, individuals who pay for Half A with a premium usually tend to be folks of coloration and feminine.^[25] Ladies are overwhelming the vast majority of Half A with a premium enrollees, making up roughly 69% of the inhabitants.^[26] CMS additionally discovered, after an inner evaluation, that QMB-eligible people who should pay for Half A with a premium are usually non-native audio system and to be decrease revenue than their free Half A counterparts.^[27]

Race & Ethnicity of Half A Enrollees

Supply: CMS, CMS Program Statistics – Medicare Complete Enrollment (2021), Tab MDCR Enroll AB 5.^[28]

Benefits to Turning into a Half A Purchase-In State

Changing to a Half A buy-in state has vital benefits for each people and for states:

• Simplifies Enrollment. Changing to a Half A buy-in state would improve the variety of folks enrolled in QMB and Medicare Half A.^[29] This may get rid of an unnecessarily complicated and irritating course of for populations with the fewest assets to navigate the method, corresponding to folks with disabilities, girls, folks of coloration, and non-English audio system. Changing to a Half A buy-in state doesn’t improve the variety of folks eligible for the QMB program as a result of it doesn’t increase the eligibility standards for the QMB program. Quite, utilizing Half A buy-in simplifies the enrollment course of for individuals who would qualify for QMB however don’t enroll due to obstacles within the group payer course of.
• Improves Well being Entry and Coordination of Care. Many low-income older adults who’ve Half A with a premium are enrolled in Medicare Half B, however depend on Medicaid for hospital providers. Beneath this enrollment situation, folks should juggle between Medicaid and Medicare suppliers for his or her medical care. Suppliers of Half B providers who refer sufferers for hospital associated providers or surgical procedure, for instance, should be positive the hospital suppliers settle for Medicaid. Making the method easier to enroll in Half A would improve the pool of medical suppliers low-income older adults can entry.
• Offers Extra Medicare Enrollment Choices. People with out Half A are prohibited from enrolling in Medicare Benefit plans – non-public plans that Medicare enrollees can select in lieu of conventional Medicare. With Half A protection, low-income older adults would change into absolutely dually eligible and have the choice to enroll in Medicare Benefit plans and particularly, Twin Eligible Particular Wants Plans (D-SNPs). D-SNPs are a kind of Medicare Benefit Plan particularly designed for dually eligible people and are required to offer care coordination between Medicare and Medicaid, a requirement not present in different sorts of Medicare Benefit plans. Medicare Benefit plans, together with D-SNPs, may additionally provide supplemental advantages, corresponding to dental or transportation, which can be particularly engaging in states whose Medicaid program doesn’t provide these providers.
• Generates Vital Financial savings for States. Past the influence on people, Half A buy-in generates vital financial savings for states by growing the variety of folks on Medicare Half A, which in flip shifts prices away from the Medicaid program and onto Medicare. Proper now, if somebody doesn’t have Half A protection, state Medicaid applications are paying for prime prices related to hospital admissions, short-term nursing facility stays, and residential well being advantages. Moreover, group payer states immediately are footing the invoice for late enrollment penalties which might be waived underneath buy-in agreements.^[30] In 2021 alone, California might have saved 8.5 million in Half A late enrollment penalties if it had been a Half A buy-in state.^[31]
• In keeping with Federal Modifications. Resulting from a latest CMS rule, it will likely be necessary for Half A buy-in states to robotically enroll all Supplemental Safety Earnings (SSI) recipients into QMB with out a separate utility, no matter their Half A premium standing.^[32] In group payer states, computerized enrollment into QMB will stay optionally available for these with Half A with a premium. But, group payer states shall be required to robotically enroll SSI recipients with free Half A into QMB.^[33] As a result of it isn’t necessary for group payer states to use this coverage to all the SSI inhabitants, this coverage excludes all different eligible people who don’t obtain SSI in addition to SSI recipients with out free Half A. Consequently, two totally different processes will apply for various populations, creating administrative complexity and confusion when Half A buy-in would supply consistency throughout populations.

Advocacy Methods for Changing from a Group Payer to a Half A Purchase-In State

The method for changing to a Half A buy-in State from a bunch payer state with the Facilities for Medicare & Medicaid Companies (CMS) is straightforward. A state simply must submit a state plan modification to CMS, which might be made at any time of the 12 months.^[34] In truth, CMS has repeatedly inspired group payer states to transform to a buy-in state. For instance, in a 2018 State Medicaid Director letter, CMS inspired group payer states to enter right into a buy-in settlement to raised serve people dually eligible for Medicare and Medicaid.^[35]

With CMS absolutely supportive of this variation, advocates want solely persuade their state Medicaid companies to take motion. But, this isn’t all the time a simple or quick course of as demonstrated by Justice in Growing old’s expertise in California detailed beneath.

Advocates in California spent a few years offering schooling to each advocates and state policymakers on the Half A enrollment course of and obstacles. Advocates developed and disseminated factsheets with directions on the “buzzwords” to make use of with SSA and county Medicaid workplaces to facilitate enrollment. But, advocates serving to their shoppers reported that native eligibility staff and SSA workers continued to wrongly flip away people making use of for Conditional Half A enrollment, both because of ignorance of the method or language obstacles. Advocates started to in earnest advocate for California to change into a buy-in state, using plenty of totally different methods:

Administrative Advocacy

Justice in Growing old and companions first approached California’s Medicaid company in 2022 with the proposal of changing to a Half A buy-in state administratively by submitting a state plan modification at their discretion. At the moment, advocates shared assets from CMS and the Built-in Care Useful resource Heart outlining the numerous benefits of changing to a buy-in state. Whereas amenable to changing to a buy-in state, the Medicaid company declined to commit to creating a change within the short-term.

Legislative Advocacy

When administrative advocacy proved unsuccessful, Justice in Growing old turned to the state’s legislature for assist. Justice in Growing old approached State Senator Susan Eggman to writer a legislative invoice in 2023, Senate Invoice 311 (Eggman) to require the state Medicaid company to submit a state plan modification to change into a Half A buy-in state by January 1, 2025. This was an interesting coverage proposal to legislators as a result of it elevated entry to well being care, with out costing the state extra funds. Senator Eggman was additionally the Chair of the Senate Well being Committee. Advocates ought to think about approaching legislators who maintain management positions. All through the legislative course of, Justice in Growing old developed and disseminated academic factsheets to legislative staffers, had ongoing conversations with the California State Medicaid Company, mentioned funding and system processing wants, requested and obtained information and demographics on the impacted populations, solicited letters of assist from companion organizations, and negotiated amendments to the enacting state rules. Advocates can think about broadly who companion organizations could possibly be, together with authorized providers and getting old suppliers, in addition to well being plans in states with necessary Medicaid managed care. Well being plans may additionally have a typical curiosity in growing the variety of full Medicare enrollees to cut back Medicaid spending.

SB 311 handed the California Legislature unanimously, and was signed by Governor Newsom in October 2023. The ultimate 2024-2025 California funds estimated hundreds of thousands of {dollars} in financial savings for each the state and federal authorities because of Half A buy-in.^[36]

Training

Along with the academic assets Justice in Growing old developed, California advocates additionally shared the Built-in Care Useful resource Heart technical help software that summarizes the financial savings and different advantages related to changing into a Half A buy-in state. Advocates highlighted the influence that the state’s group payer standing had on particular populations, particularly in a various state corresponding to California. Advocates in different states can strategy their state Medicaid companies with comparable arguments, and, if attainable, request demographic information to reinforce their place. Since Half A late enrollment penalties are waived for Half A buy-in states, advocates can spotlight these computerized financial savings to their Medicaid companies together with shifting prices to Medicare from Medicaid for Half A coated providers.

Conclusion

Half A buy-in is an equitable technique to eradicating administrative obstacles that forestall older adults from getting assist with costly Half A premiums. Changing to a Half A buy-in state doesn’t modify eligibility limits and improve caseloads by increasing eligibility. It merely removes obstacles that forestall low-income older adults from accessing help they in any other case qualify to obtain. It is usually well timed and in step with CMS’s different efforts to extend enrollment into Medicare Financial savings Applications. Half A buy-in is an easy resolution with a two-fold influence: financial savings for state Medicaid applications and lowering inequities by eradicating administrative burdens for older adults who’re disproportionately girls and other people of coloration.

Sources

Endnotes

1. As of December 2023, there are 66.9 million Medicare enrollees. Heart for Medicare and Medicaid Companies (“CMS”), Medicare Month-to-month Enrollment, accessed April 1, 2024. ↑

2. Roughly 99% of Medicare enrollees wouldn’t have a Half A premium. Heart for Medicare and Medicaid Companies, 2024 Medicare Components A & B Premiums and Deductibles, (October 12, 2023). ↑

3. CMS, Medicare Month-to-month Enrollment, accessed April 1, 2024. ↑

4. Half A late enrollment penalties might improve the bottom Half A premium. CMS, CMS Program Statistics – Medicare Premiums, MDCR Premiums 1 tab, 2021, accessed April 23, 2024 ↑

5. Sure particular enrollment intervals may additionally be out there. See Social Safety Administration, Program Operations Handbook System (“POMS”), HI 00801.133 Enrollment and Protection Intervals; see additionally CMS, When Does Protection Begin?. ↑

6. CMS makes use of the time period “premium-free Half A.” Premium-free Half A refers to people who don’t pay a month-to-month premium to acquire Half A protection. This transient will use the time period “free Half A” to seek advice from premium-free Half A. ↑

7. The variety of work credit is determined by whether or not an individual is making use of for Half A based mostly on age, incapacity, or Finish Stage Renal Illness. See 42 U.S.C. § 1395c; 42 C.F.R. § 406.10; CMS, Unique Medicare (Half A and B) Eligibility and Enrollment. ↑

8. CMS makes use of the time period “premium Half A.” Premium Half A refers to people who wouldn’t have the required work credit to qualify at no cost Half A and procure Half A by paying a month-to-month premium. This transient will use the time period “Half A with a premium” to seek advice from premium Half A. ↑

9. Folks with no less than 30 quarters of labor pay $278 a month. These with lower than 30 quarters, pay $505 a month in 2024. CMS, 2024 Medicare Components A & B Premiums and Deductibles. ↑

10. CMS Program Statistics – Medicare Premiums, excel spreadsheet MDCR Premiums 1 tab. ↑

11. 42 CFR 406.32(d). ↑

12. CMS Program Statistics – Medicare Premiums, excel spreadsheet MDCR Premiums 1 tab. ↑

13. Individuals who don’t qualify at no cost Half A might as a substitute enroll in a Market plan in the event that they drop their Half A and B, or don’t enroll in Half A with a premium or B once they first change into eligible. This will result in Half A and B late enrollment penalties in the event that they subsequently enroll in Medicare Half A or B sooner or later. CMS, Ceaselessly Requested Questions Concerning Medicare and the Market, (August 2014), at Part A.6 p. 5. ↑

14. Advocates can discover extra assets on Improper Billing and template pattern letters at Justice in Growing old’s Improper Billing webpage. ↑

15. Social Safety Act 1905(p)(1)(A) and 42 CFR 435.123; POMS HI 00801.139 Certified Medicare Beneficiary Provisions. ↑

16. Enrollment in premium Half A requires simultaneous enrollment in Half B. POMS HI 00801.131 Eligibility for Premium-HI. ↑

17. Georgia Burke, Social Safety Company Clarifies Dealing with of Medicare Half A Conditional Purposes, Justice in Growing old, (January 2023). ↑

18. Social Safety Administration, Program Operations Handbook System (“POMS”) HI 00815.001 State Cost of Medicare Premiums (Purchase-In Program). ↑

19. Sections 1843(a) and 1818(g) of the Social Safety Act; CMS, Handbook for State Cost of Medicare Premiums, Chapter 1: Program Overview and Coverage, (Revised April 2024), Part 1.2.↑

20. POMS HI 00801.140 Premium-Half A Enrollments for Certified Medicare Beneficiaries (QMBs) – Half A Purchase-In States and Group Payer States ↑

21. CMS, Handbook for State Cost of Medicare Premiums, Chapter 1: Program Overview and Coverage, Part 1.11. ↑

22. 42 CFR 406.26; POMS, HI 00815.001 State Cost of Medicare Premiums (Purchase-In Program). ↑

23. 42 CFR 406.26(a)(2); State Cost of Medicare Premiums, Chapter 1, Part 1.10. ↑

24. California Welfare & Establishments Code 14005.11(g); California Division of Well being Care Companies, All County Welfare Director’s Letter MEDICARE PART A BUY-IN AND AUTOMATIC ENROLLMENT OF SUPPLEMENTAL SECURITY INCOME RECIPIENTS INTO QUALIFIED MEDICARE BENEFICIARY PROGRAM 24-01 (January 2024). ↑

25. CMS Program Statistics – Medicare Premiums, MDCR Premiums 2 tab, 2021, accessed April 23,2024. ↑

26. Id. ↑

27. CMS, at 87 Fed. Reg. 54760 at 54773. ↑

28. CMS Program Statistics – Medicare Complete Enrollment, 2021, accessed August 22, 2024. ↑

29. Moreover, changing to a Purchase-In state can successfully get rid of Half A late enrollment penalties for people even when they lose Certified Medicare Beneficiary eligibility sooner or later. If an individual loses QMB eligibility and State fee of Half A premiums ends, the individual shall be chargeable for the usual Half A premium solely, even when they owed a late enrollment penalty previous to Half A buy-in. See 42 CFR 406.26(d)(1)(i); Handbook for State Cost of Medicare Premiums, Chapter 1: Program Overview and Coverage, Part 1.15. ↑

30. Andrew DuJack and Maria Dominiak et.al., Assessing the Fiscal Viability of a Medicare Half A Purchase-in Settlement in Group Payer States, Built-in Care Useful resource Heart, (December 2021). ↑

31. CMS, CMS Program Statistics – Medicare Premiums, MDCR Premiums 3 tab, (2021). ↑

32. 42 C.F.R. § 435.909; Rachel Gershon, Ultimate Rule to Streamline Enrollment in Medicare Financial savings Applications, Justice in Growing old, (November 2023), at web page 2. ↑

33. Id. ↑

34. 42 CFR § 406.26(a). ↑

35. CMS, Ten Alternatives to Higher Serve People Dually Eligible for Medicaid and Medicare, (December 2018); see additionally Ceaselessly Requested Questions on Medicare Half A and B “Purchase-in,” at web page 2. ↑

36. California estimated roughly annual financial savings of $1.3 million Normal Fund and $40.1 million federal funds. California Senate Funds and Fiscal Evaluate, Subcommittee No. 3 Agenda , at p. 17 (Could 2024). ↑