Securing Primary Medical and Payment Benefits for Costly Populations

September 15, 2015

Sometimes, we may not realize that patients with costly conditions qualify for Social Security or Medicare benefits. Patients may be eligible for Social Security Disability Insurance benefits (SSDI) and Medicare, even if they aren’t yet 65 years old. If the patient is disabled they may qualify for Medicare coverage based on their disability, diagnosis or age. The trouble is, they and their health plan, employer or insurance company may not know they’re eligible or how to go about obtaining benefits. So, how can health plans, insurers, individuals and employers take advantage of these savings? They need an advocate.

Advocacy services can help

PartnerRe provides advocacy services through our PULSE + Plus™ Medical Management Program. This program provides appropriate SSDI advocacy and coordination of Medicare benefits through information and services to qualifying patients, spouse and dependents. It helps them navigate the process of obtaining SSDI benefits leading to Medicare primacy and helps the insurer, employer or health plan reduce their healthcare spend. Here’s how it works.

An advocacy partner surveys client data and Medicare rolls to uncover individuals, spouses and their dependents to determine whether they may be eligible for advocacy services. Each individual’s case is reviewed to see whether it meets the technical and medical requirements of the Social Security Administration (SSA). For example, the individual, spouse or his or her dependent(s) must

  • Have satisfied employment qualifications;
  • Be unable to work due to a condition or disability restricting their ability to work; and
  • Meet Social Security’s requirements for disability

In addition to working with payers and patients meeting disability requirements, our advocacy services look at myriad other ways the individual, spouse, dependents or partner may qualify for assistance, resulting in the offsetting of risk to an alternative payer.  For example, another scenario includes an insured who is over 65 years of age, participates in health coverage through an exchange plan, is not working, and yet who has not signed up for Medicare.  Since they have not signed up for Medicare, this results in a higher cost of care for them and the health exchange, for the management of their medical condition.  Another example is a member who has a qualifying condition such as ALS or end stage renal disease. A third example is where some insurers, health plans or employers may not be aware a member is already Medicare primary and are assuming the role of primary payer themselves.

We provide professional representation throughout the process, from identification, through the onerous application and any appeal process – resulting in judgment and award. Our advocates increase the rate of acceptance for SSDI as well as other advocacy benefits, resulting in health care savings for both the payer and the individual.

Benefits of advocacy

PartnerRe’s advocacy services provide benefits to individuals, health plans, insurers and employers. For individuals, the program may reduce their out of pocket medical spend.  It may also provide them with a richer retirement benefit. For health plans, insurers and employers, coordination of benefits can help them insure that:

  • Qualified, disabled individuals are identified to receive SSDI
  • Medicare correctly pays the claims as the primary payer for pre-65 insured persons who are disabled
  • Effective coordination of Medicare benefits for qualified, disabled individuals are managed and delivered
  • Significant annual savings to retiree health plans and reduction of retiree health care liability are realized

Is advocacy right for your clients?

PartnerRe’s advocacy services offer a large potential for recovery by the insurer, employer or health plan. Data is required for advocacy services, however including:

  • Patient demographic data, such as age, healthcare coverage and employment status
  • Information about individuals’ pharmaceutical and clinical encounters
  • Employment status, healthcare coverage, Medicare indicator, and the like

Social Security and Medicare benefits are an important resource in the payment landscape. Advocacy can help health plans, insurers and employers take advantage of all the opportunities to enhance their clinical and financial outcomes.

Can your business, health plan insurers or employers benefit from advocacy services? Contact the experts at PartnerRe Health for more information.

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