Response to 60-day Public Comments

CMS-2421-P

I. Comment Responses

We received no comments related to our estimated baseline costs of implementing the Medicare Savings Programs (MSPs) and the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) or our estimated costs and savings related to implementing the September 3, 2023 MSP final rule.¹ We are not making any changes to those estimates here.

We received several comments on our revisions to the model MSP application. Many commenters provided feedback on multiple topics related to the application.

Comment: In general, commenters applauded CMS’ efforts to update the model MSP application. They noted that the changes made the application clearer and easier to complete. One commenter specifically appreciated changes discussing how to apply for full Medicaid coverage, the inapplicability of estate recovery to MSPs, and the impact of MSPs on Part B premium deductions from benefit checks.

Response: We thank the commenters for their support of the revisions to the model MSP application. The MSPs play an essential role in the health and economic well-being of those enrolled, promoting access to care and helping free up individuals’ limited income for food, housing, and other life necessities. We hope that this simplified and streamlined MSP-only application provides states with a foundation they can use and tailor as needed. Ultimately, our goal is to streamline the MSP application process to increase the enrollment of eligible individuals in the MSPs.

Comment: We received a small number of comments addressing formatting and versioning of the model application. One suggested aligning all text to the left for improved readability. Another recommended creating two versions of the model MSP application, one with asset questions and one without asset questions.

Response: We have revised the formatting to make the form easier to read. With regard to the suggestion that we alter the alignment of the model MSP form, we note that most of the text is currently aligned left, and we believe the current alignment of those pieces that are not makes good use of the space available on the form.

With regard to the suggestion that we create two versions of the model MSP application form, we appreciate the comment but decline to create two versions. The model MSP form reflects minimum federal guidelines for the MSPs. We recognize that states have flexibility in both their eligibility standards and their application procedures that may differ. When we make the application available, we will encourage states to adapt the model application to reflect their program rules, especially if they disregard assets.

Comment: A commenter offered several suggestions on increasing accessibility. The commenter recommended that we increase the number of translated languages from 10 to 20, citing the recently finalized section 1557 regulations and the 2024 CMS Health Equity Framework, and that we add information in the multi-language insert on how to get help in other languages. The commenter also suggested that we undertake user testing to ensure that the form is accessible through various screen reader programs and that the signature and verification process can be completed by individuals with blindness or low vision without assistance.

Response: We agree with the commenter on the importance of offering translations to increase accessibility of the model MSP form. In response to this comment, we will translate the model MSP into the 15 most commonly used languages nationally. We agree with the commenter’s suggestion to include instructions on accessing interpreter services in the multi-language insert.

We agree that it is important that the form be accessible for individuals who have low vision. We will ensure that our forms are accessible for individuals with disabilities under section 508 of the Rehabilitation Act, that screen readers can read the form, and that individuals with low vision can fill out the application. While we are not undertaking user testing at this time, we appreciate the suggestion and will consider user testing in the future.

Comment: Some commenters expressed appreciation for the instructional sheet in the application but recommended adding additional detail for applicants and assisters. One commenter requested that CMS define terms, such as “Extra Help” and “cost-sharing,” clarify the distinction between full Medicaid and the MSPs, and explain how each MSP helps pay premium and out-of-pocket costs. A second commenter suggested adding that the MSPs help to enroll individuals in Medicare Parts A and/or B. Another commenter suggested we explain that the Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) groups provide retroactive benefits. The commenter also suggested adding language to convey that individuals do not need to pay back MSP benefits after the existing statement that estate recovery does not apply. One commenter asked that we add step-by-step instructions on completing the form, including guidance on determining what counts as income and how to value a vehicle.

Response: We appreciate the commenters’ suggestions. In general, we aim to keep the introductory section streamlined and generally applicable to most individuals. We will encourage states to tailor the instructions based on their state rules and other factors. We decline the suggestion to add definitions of Extra Help and cost-sharing since we believe that the current description is adequately descriptive. We agree with the suggestion to clarify the distinction between the MSPs and full Medicaid benefits. To that end we have changed the language to state that “this is NOT an application for other Medicaid benefits such as long-term services and supports.” We decline the suggestion to further explain how each MSP helps with premium and cost-sharing as the form instructions already explain that QMB pays Medicare Part A and/or B premiums and cost-sharing and that SLMB and QI pay Part B premiums. We also decline to add information explaining that the MSPs help individuals enroll in Medicare Part A or B since this only applies to people who are not already enrolled in Part A or Part B, and only under certain circumstances.

We agree with the suggestion to add more information about estate recovery and have updated the instructions to state, “You will NOT need to pay back any help you receive through a Medicare Savings Program.” We appreciate but decline the suggestions to add step-by-step instructions for applicants and to include information about retroactive coverage for SLMB and QI coverage. We are looking to strike a balance between providing sufficient information for individuals to understand the form without making it so long that individuals may be discouraged from completing it.

Comment: Some commenters suggested providing more detailed information about Extra Help and enrollment in QMB for individuals who lack premium-free Part A. Two commenters suggested adding information about the timeframe for individuals to be enrolled in Extra Help and a sentence telling individuals to call their state if they do not get enrolled in Extra Help. Some commenters suggested that we add more specificity about enrollment in Part A, including conditional enrollment. One commenter also asked that the text regarding deduction of Part B premiums from social security, railroad retirement, and civil service benefits mention that the deductions also apply to Part A for QMBs.

Response: We appreciate the suggestions but decline to add language about Extra Help timeframes or instruct individuals to contact their state if they have not received Extra Help, as processing times vary. We are not aware of any systematic issue with MSP-enrolled individuals getting enrolled in Extra Help and are concerned that adding language not needed for MSP enrollment may make the application too long. We do not want to discourage individuals from completing it. We also decline to provide additional detail about Part A enrollment, which depends on whether a state is a Part A buy-in state or a group payer state and other variables. We plan to recommend that states modify the model instructions and applications consistent with their state policies. We also decline the suggestion to add a statement that Part A premiums would be deducted from benefit payments. The statement would be incorrect because those without premium-free Part A pay their premiums through direct billing since they are not receiving any social security retirement or disability benefit payment. Further, most QMB-eligible individuals without premium-free Part A are unable to afford Part A, so few would have Part A coverage prior to enrolling in QMB.

Comment: We received several comments on the “what you need to apply” section of the application. One commenter suggested that we remove the statement that proof of citizenship is required, because Medicare recipients who declare U.S. citizenship are not required to provide additional proof as a condition of eligibility when applying for Medicaid. The commenter also suggested defining “eligible immigration status” and including more information about what constitutes eligible immigration status. One commenter also asked us to change “proof of residency” to “proof of where you live” in order to improve readability. Two commenters objected to our removal of the reference to using additional pages.

Response: We agree with the suggestion to remove proof of citizenship for the MSPs. As the commenter noted, under 42 CFR 435.406(a)(1)(iii)(B), Medicare recipients who declare U.S. citizenship are not required to provide additional proof as a condition of eligibility when applying for Medicaid. We also appreciate the comment suggesting that we add additional detail for non-citizens and are changing the model form to provide examples of documentation required for non-citizens. 

We decline to provide additional explanations about immigration status. Individuals in numerous immigration categories can be eligible for Medicaid coverage, and it would not be practical to list them all on this application. The individual may also ask the state Medicaid agency if they are unsure if they qualify. We agree to make the change to “proof of where you live” for additional clarity. We also will restore the reference to using additional pages if an individual does not have enough space on this application.

Comment: We received a few comments on methods of application. A commenter strongly supported providing multiple ways to apply. The commenter also asked us to remind states of the requirement to accept faxed applications by including a line item for a fax number for application submission, and another asked us to remind states of the requirement to make paper application forms readily accessible.

Response: We agree it is important to note that, per 42 CFR 435.907(a), states must accept applications through several different modalities, including paper applications. We also accept the recommendation to provide a line item for a fax number.

Comment: Two commenters made suggestions on the “what happens next” section of the application. A commenter asked to change the title to “what happens after I submit my application” and to provide information on what individuals can do after not hearing from a Medicaid agency within 45 days. Another commenter asked for language to inform individuals

that if their application is approved, “it can take up to 90 days after the approval for the Social

Security Administration to stop deducting Part B premiums, but s/he will be reimbursed back

to their MSP start date.”

Response: We decline the suggestions to change the section title, as we believe “what happens next” is sufficiently clear. We agree that it is important that individuals know what to do if they do not hear back within 45 days and note that the application as currently drafted advises that they should contact their state Medicaid agency in this situation. With regard to the suggestion that we provide information on timelines for SSA to stop or reimburse for deductions from individuals’ social security checks after an MSP application is approved, we do not believe the MSP application is the appropriate place for this information. We note that the application does provide information on how to contact the SHIP with questions. States also may use the MSP approval notice to provide a new enrollee with information on SSA timelines and processes.

Comment: Two commenters suggested adding 1-800-Medicare contact information to the “get help with Medicare” section of the application.

Response: We decline to add the 1-800-Medicare number to the model MSP form. In consideration of this comment, however, we are changing the title of the section currently titled, “Get help with Medicare questions” to “Get help with questions about Medicare Savings Programs” to reflect that the SHIP is the best point of contact to provide support with the MSP application form or other MSP questions.

Comment: Several commenters made suggestions on information regarding either the applicant or their household. One commenter recommended that the options for an applicant’s marital status be more narrowly tailored to address different situations such as “Not married (Single/divorced/widowed), Married and living with spouse, and Married but separated from spouse.” For the latter category, the commenter also recommended collecting identifying information for the spouse when the applicant is separated. Another commenter asked us to clarify whether the application can be filled out by a couple or must be filled out separately by each individual person.

Other commenters made recommendations concerning the question on gender identity, stating we should spell out “Male” and “Female”; add “non-binary” and “prefer not to answer” as options; consult with SAGE national resource center on the appropriate options; and provide instructions on how to fill out this section. A few commenters had different suggestions for who should be listed as a household member. One commenter stated that additional household members who could not also be applying for MSPs should be removed from the application in order to streamline it. Another commenter proposed to remove all entries in the “relationship to you” column to increase form flexibility. A third commenter said that we needed to add information about the student status of children for states to determine whether the child is included in the applicant’s MSP group.

Other comments regarding the personal information/household section focused on clarifying the need for social security number and immigration status. Specifically, a commenter asked us to clarify that a social security number is not required for any spouse or dependents who are not also applying for MSP benefits. A commenter urged us to make it clearer that immigration status for a spouse is only required if the spouse is applying for an MSP. Separately, a commenter noted that we should modify the application to invite applicants to provide information about race and ethnicity on a voluntary basis.

Response: We agree with the suggestion to modify the fields regarding marital status to include more categories within the existing “Not married” and “Married” categories. We decline to request details with respect to a separated spouse, as we anticipate there may be scenarios in which this information is not needed and providing it may be burdensome for an applicant. We agree with the commenter’s suggestion that we further clarify whether the application can be filled out by a couple or must be filled out by each individual person. We added an explanation in the instructions that a spouse may also apply using this application.

With regard to the gender identity comments, we agree that additional options should be provided to applicants and appreciate the various proposals offered by commenters. We have chosen to use terminology consistent with guidance that CMS has provided to state Medicaid agencies on sexual orientation and gender identity questions.² We also have moved questions about gender and sexual orientation to the end of the application in a section that also provides the applicant the option to provide information on ethnicity and race identification. The race and ethnicity categories are consistent with those used in the Health Insurance Marketplace application.³ We decline to provide detailed instructions on how to fill this section out, as we expect individuals will fill this application out consistent with how they identify themselves.

We decline to accept the suggestion to remove “Spouse” as a category and replace it with “other” for individuals who are living together, but unmarried. Under 42 CFR 435.602(a)(2), the income and assets of a spouse specifically count in the MSP eligibility determination of an individual whereas individuals who are not married and are living together do not.⁴ We also decline to remove the rows for additional family members from this section because, no later than April 1, 2026, 42 CFR 435.601(e) requires states to define “a family of the size involved” for the MSPs to be no less than the LIS definition: the applicant, the applicant’s spouse, and certain other financially-dependent relatives living in the same household. We also decline to accept the suggestion to include information about the “student status” for consideration in family size, because student status is not generally relevant in determining MSP eligibility.

We agree with the suggestion to revise the form to indicate that a social security number is not required for any spouse or dependents who are not also applying for MSP benefits. We agree with the commenter that this information is not required by law and requiring it could potentially deter individuals from applying. Similarly, we accept the recommendation to make it clear that individuals only need to provide immigration status for a spouse if the spouse is also applying for MSP benefits. We also accept the suggestion to revise the form to allow applicants to voluntarily provide information about race and ethnicity. Across programs at CMS, we continue to improve our data collection efforts to make progress towards achieving health equity and better understand the individuals we serve.

Comment: We received several comments concerning changes to the application form related to Medicare information. One commenter asked us to briefly explain where to find the individual’s Medicare number in order to list it on the application, while another commenter asked us to include a box for applicants to check if they had conditional Part A along with language about processing QMB applications with conditional Part A enrollments. Another commenter recommended defining Medigap in the “other health information” section, while a different commenter recommended adding Medicare Advantage as an example in the “other health information” section.

Response: We appreciate the comments seeking to add more information and clarity around Medicare information; however, we do not think it is necessary to add information about where to find individuals’ Medicare number. Medicare beneficiaries use their Medicare number to access all Medicare services, so we expect they are familiar with it. We also decline to include a check box for conditional Part A enrollment. As explained above, conditional Part A enrollment is complicated, and it is mostly relevant in group payer states. We think that given those issues, including such additional information may create confusion.

With respect to listing of other insurance, we decline the recommendation to add a definition of Medigap since we believe that individuals with Medigap policies are familiar with the term. We also will not add Medicare Advantage as an example of other health coverage since Medicare Advantage is encompassed within Medicare coverage and states can easily access CMS data on whether an individual receives Medicare coverage through original Medicare or a Medicare Advantage plan and can also access the identity of the specific plan.

Comment: We received a few comments on the “income” section of the model MSP form. One commenter recommended that we add “debit/pre-paid cards” to the list of income types. The commenter explained that many Medicare recipients receive their monthly social security benefits via pre-paid cards such as Direct Express. The commenter further expressed their belief that, if an MSP applicant doesn’t declare ownership of any bank account, Medicaid agencies may question how monthly social security payments are received. The commenter expressed their hope that this change would prevent procedural denials. Another commenter made several suggestions for the income section of the application. First, the commenter suggested substituting “recipient’s name,” with plain language alternatives such as “who gets this income.” Second, the commenter recommended adding pension, annuities, and rental income as examples of income. Finally, the commenter recommended that we distinguish income from employment and self-employment to provide Medicaid agencies sufficient detail about earned income.

Response: We thank commenters for their suggestions. We decline the suggestion to add “debit/pre-paid cards” to the list of income types. We believe that the existing inclusion of “social security benefits” as an example of a type of income covers social security payment made through prepaid cards. We do not wish to introduce confusion between those and other prepaid cards that are not countable income. We agree that we should use plain language as much as possible and have revised the application to read “Who gets this income.” We note the application already includes self-employment and rental income as examples of common forms of income in the “income” section of the application and decline to add other examples as the list is not meant to be exhaustive.

Comment: Commenters made several suggestions in the asset section of the application with a few focusing on a specific asset, such as vehicles or life insurance, and other comments discussing assets more broadly. A commenter recommended that we provide additional information about pre-paid goods and services intended for final expenses and an explanation about how to claim a burial fund exemption without a contract. The commenter explained that this information would be useful because burial funds are an underutilized path to enrollment for individuals whose countable assets are only slightly over program limits. The same commenter also recommended that the application form collect information about the financial institution and account number where a person keeps their assets, so state Medicaid agencies can efficiently compare self-attested resources with information provided by asset verification systems (AVS), eliminating the need for paper verifications from the individual.

A commenter recommended adding a place on the vehicle table to indicate vehicle use (for example, personal, medical, employment, home) because the current classification of primary versus other did not capture the vehicle with the highest equity value that the individual could exempt under current law. Another commenter suggested adding information instructing applicants on how to value their vehicle.

One commenter suggested using more plain language to describe property by substituting “real property” for homes or land that you own, but don't live in. For the life insurance section, one commenter requested that we revise the life insurance information to more accurately reflect the policy stated in sections 1613(a)(16) and 1905(p)(1)(C) of the Social Security Act that life insurance cash value is only counted if the total face value of all life insurance policies generating cash value exceeds $1,500. Another commenter recommended the application form collect the life insurance agent’s name and the insurance company address and/or phone number so states have sufficient information to verify current cash value per the requirement at 42 CFR 435.952(e)(4)(iv)(A). Another commenter stated there should be a box to check for an applicant not knowing how much life insurance is worth and a box to check for asking the state to help with life insurance evaluation. Additionally, the commenter stated that the instruction sheet should provide information on how to assess the value of life insurance.

Response: We appreciate the many suggestions of commenters about this section. We decline to provide additional information in the application about how to claim a burial fund exemption without a contract. As we stated earlier, we are seeking to streamline the application as much as possible and, while this type of information is useful, we think this content is more suited for education and outreach materials rather than text for the application itself. We are also declining the suggestion for putting financial institutions and accounts on the application itself. We do not want to unnecessarily lengthen the application when states have different practices regarding verifying this information.

We do not agree that adding a place on the vehicle table to indicate vehicle use (with examples, i.e. personal, medical, employment, home) would be helpful because the purpose of the vehicle use does not tell the Medicaid agency which vehicle to exclude whereas the current designation of primary versus other does. Under 20 CFR 416.1218, which generally governs MSP eligibility determinations,⁵ one vehicle regardless of value is excluded from an SSI eligibility determination. Additionally, while we think information instructing applicants on how to value their vehicle could be useful, it is a more appropriate topic for outreach and education.

We accept the suggestion to use plain language to describe property and have substituted “homes and land that you own (excluding primary residence),” for “real property.” For the life insurance section, we have changed the instructions so that they now request policies with a “face” value above $1,500 rather than a “cash” value. We appreciate that the commentator identified this error. We decline the suggestion to add the life insurance agent’s name and the insurance company address and/or phone number to the application. The application collects the name of the insurance company and policy number, which we believe is sufficient for states to obtain needed information. We are also adding a box for the applicant to check to request the state’s help with life insurance valuation. In addition, in the section immediately above the declaration and signatures section, we added a statement authorizing the state to contact the applicant’s life insurance company on the applicant’s behalf. We think these additions will be useful to the applicant. We decline the suggestion to provide information on how to assess value of life insurance since, under 42 CFR 435.952(e)(4)(iv)(A), states are required to help the individual assess the cash value of life insurance for amounts over $1,500 if the individual provides their consent.

Comment: There were a few comments on appeals language. One comment recommended moving appeals language from its current place at the bottom of the application to the “what happens next” section because that section better relates to the appeals information. Two comments focused on removing the phrase “in many cases” from appeals language and suggested instead to simply say “if you don't agree with our decision, you can ask for an appeal.” The commenters noted that the language is confusing and could discourage people from filing an appeal. Another commenter suggested deleting the phrase relating to “keeping coverage while appeal is pending” because it is only applicable when existing coverage is ending and not relevant for new applications.

Response: We disagree with moving the appeals language, as we believe its present location, directly above the declaration and signatures section, helps ensure that it is carefully read. We also note that detailed information about the appeals process is included in MSP denial notices. We agree with the comments to remove the phrase “in many cases” and changed the appeal language to say “if you don't agree with what you qualify for, you can ask for an appeal.” Similarly, we are removing the phrase related to “keeping coverage while appeal is pending.”

Comment: There were several comments regarding the signature and declaration section at the end of the MSP model application. One commenter recommended adding authorization to obtain life insurance verification. The commenter noted that, for state Medicaid agencies to obtain verification of life insurance on applicants’ behalf in accordance with the provision at 42 CFR 435.952(e)(4)(iv)(A), they will likely need specific authorization. The commenter recommended the authorization language be incorporated into this section, so an additional form and signature would not be needed. Another commenter recommended clarifying the need for a spouse’s signature. The commenter noted that some states require both spouses to sign the application when both are applying, whereas other states only require the signature from one of the spouses. Another commenter recommended modifying the section discussing designating a representative and noted that the form should allow the applicant to specifically authorize permissions outlined in federal regulations at 42 CFR 435.923 and that we should add the authorized representative’s e-mail address. A third commenter asked for added information regarding further guidance on what is considered a change in circumstances. The commenter noted that the current language makes it seem as though the applicant always had to provide updates to the Medicaid agency whenever there was any change, even if their savings account only changed by a few dollars.

Response: We agree that state Medicaid agencies will need to obtain consent of the individual to obtain verification of life insurance on applicants’ behalf and, as noted above, have added language as suggested by the commenter. We decline to clarify the need for a spouse’s signature. As the commenter noted, states’ signature requirements may differ but, as with many other items on this model application, we have chosen to prioritize simplicity. We also decline to list the full scope of the permitted actions of an authorized agent. For purposes of the MSP application, the most relevant actions are signing the application on the applicant’s behalf and receiving communications from the agency regarding the MSP application. As such, we do not believe further details are needed and could be confusing. We agree with the recommendation to provide the representative’s e-mail address. We decline to provide further guidance on change of circumstances in the MSP application, another area where state reporting requirements differ. States may modify this model application to address this issue.

Comment: There were also several comments out of scope for the MSP model application. One commenter stated that we need to provide more information on the conditional enrollment process, which is very confusing for beneficiaries. Another commenter noted that some state Medicaid staff are unfamiliar with buy-in processes and need more education. Another commenter noted that a particular state’s application and system of noticing people is confusing, that telephone wait times are long, and that the online portal is not secure. Another commenter stated that MSP and LIS are good programs and help reduce costly hospital visits. One commenter noted that many states do not use MSP-only applications and require information not necessary for determining MSP, providing an example where such states might fail to determine eligibility for both MSP and full Medicaid coverage. The same commenter suggested improvements for these states’ eligibility determination processes. The commenter also stated that several states require information on their MSP-only application that is not required for determination of MSP eligibility and provided examples.

Response: Although beyond the scope of this package, we appreciate that commenters have shared specific information and suggestions on challenges that individuals have encountered in MSP enrollment.

1 “Streamlining Medicaid: Medicare Savings Program Eligibility Determination and Enrollment” (88 FR 65230).

2 Guidance on Adding Sexual Orientation and Gender Identity Questions to State Medicaid and CHIP Applications for Health Coverage (CMCS Information Bulletin, Nov. 9, 2023), available at https://www.medicaid.gov/sites/default/files/2023-11/cib11092023.pdf

3 Application for Health Coverage & Help Paying Costs, OMB No. 0938-1191, available at https://www.cms.gov/marketplace/applications-and-forms/marketplace-application-for-family.pdf.

4 In making MSP eligibility determinations, the state also cannot count the income of spouses who cease to live together.

5 Section 1905(p) of the Act directs that the income and resource methodologies applied by the Social Security Administration in determining SSI eligibility per sections 1612 and 1613 of the Act be used to determine financial eligibility for the MSPs, except that states may employ less restrictive income and/or resource methodologies than those applied in determining SSI eligibility under the authority of section 1902(r)(2) of the Act.