Enrollment in Medicare Part D Subsidy Program and Cognition Skills

Beneficiaries who are enrolled in Medicare Part D who have limited income and resources are eligible for a low-income subsidy (LIS) that offers cost-sharing and premium assistance to reduce out-of-pocket costs for prescription drugs. Beneficiaries who receive Medicaid, Medicare Savings Programs, or Supplemental Security Income benefits receive the LIS automatically.

Other Medicare enrollees must apply for the LIS and have to meet specific income and resource requirements to qualify. According to researchers, take-up of the LIS by those eligible enrollees has been “remarkably low.” Only 42.2% of the eligible group applied for and received the subsidy.

One explanation for the low rate of take-up of the LIS may be that elderly citizens with cognitive deficits are vulnerable to making poor enrollment decisions. Noting that the association between cognition and take-up of the LIS has not been directly examined, the researchers recently conducted a data analysis to examine the role of beneficiaries’ cognitive abilities in the process of decision-making regarding enrolling for the LIS. The analysis also compared out-of-pocket drug spending and premium costs between those receiving and not receiving the LIS.

Results were reported in JAMA Internal Medicine [2013;173(12):1100-1107].

The researchers utilized data from 2006, 2008, and 2010 waves of the nationally representative Health and Retirement Study. The analysis included data on elderly Medicare beneficiaries >50 years of age who were likely eligible for the LIS (based on reports of household income and assets as well as program rules governing eligibility thresholds). Medicaid beneficiaries and recipients of Supplemental Security Income who receive the LIS automatically were excluded from the analysis.

Those who did not enroll in the LIS program were older, had poorer cognition skills, and were less likely to use prescription drugs regularly. They were also in better health, had fewer chronic conditions, were more likely to be veterans, and less likely to be depressed and female.

The researchers compared those eligible for the LIS in the top quartile of overall cognition with those in the bottom quartile. Those in the bottom quartile were significantly less likely to report enrollment in Medicare Part D (adjusted rate, 63.5% vs 52.0%; P=.002), awareness of the LIS (58.3% vs 33.3%; P=.001), and application for the LIS (25.5% vs 12.7%; P<.001).

Among those in the target population who enrolled in Medicare Part D, self-reported receipt of the LIS was associated with significantly lower annual out-of-pocket drug spending (adjusted mean difference: −$256; P=.02) and premium costs (−$273; P=.02).

The researchers summarized their findings, stating, “Among Medicare beneficiaries likely eligible for the Medicare Part D LIS, poorer cognition and numeracy are associated with lower reported take-up. Current educational and outreach efforts encouraging LIS applications may not be sufficient for beneficiaries with limited abilities to process and respond to information.”