Cost Avoidance Through SSDI and Medicare Enrollment

Private employer health plans face significant challenges due to aging populations and the rising costs of health care. PCG Health's Disability Determination & Medicare Enrollment (DDME) consulting services assist health plans in managing these economic and demographic changes. Our knowledgeable team can help identify individuals who have disabling conditions that may make them eligible for Social Security Disability Insurance (SSDI) benefits and ultimately eligible for the federal Medicare program. Our services offer considerable benefits to health plans, enabling them to shift claims for high-cost members to the Medicare program and to members who are eligible for cash benefits upon enrollment into SSDI. With more than 20 years of experience in the field, PCG has a proven record of results, as evidenced by our successful enrollment of tens of thousands of individuals into SSDI and Medicare.


Transitioning one high-cost member to Medicare primary can save a plan nearly $40k per member annually!

The Path to Medicare

SSDI enrollment is the first step in the path toward obtaining Medicare coverage. Medicare coverage begins 24-months after the onset of a disabling condition. Eligibility may be established up to a maximum of 12 months prior to the date of application. Immediate Medicare enrollment exceptions are applicable for certain Social Security Administration (SSA)-designated diagnoses (e.g., endstage renal disease and amyotrophic lateral sclerosis). With the disproportionately large share of costs incurred by the disabled population, cost avoidance upon transition to Medicare may be dramatic. Health plan members become Medicare eligible 12-24 months following SSDI enrollment.

The PCG Project Approach

PCG Health presents a complete and automated solution, working directly with identified plan members and the SSA throughout the enrollment process. Our team leverages human and technical expertise accrued over many years to maximize successful enrollments. Several attributes distinguish our approach:

  • Data-driven diagnostic predictive modeling and targeting – The traditional approach to disability enrollment is often passive and initiated by the claimant. Our approach uses paid claims, demographic, and eligibility data to identify and prioritize members with high likelihoods of successful enrollment.
  • Success-based pricing model – PCG works with each health plan to develop a pricing model that meets the unique needs of that plan. We prefer to accept reimbursement based upon the benefits that our client derives from our services. A fee-per-enrollment model directly benefits plans. This model incentivizes efficiency and accuracy in the identification process.
  • Hands-on advocacy approach to representation – Each member will be assigned to a single PCG advocate with whom the member will work throughout the application process. PCG advocates strive to minimize the burden of the enrollment process on the member.
  • Comprehensive SSA disability expertise – PCG leverages more than 20 years of federal disability determination and SSDI benefit management experience with private health plans and state and local government entities. We thoroughly understand and manage all aspects of the disability enrollment process and have established constructive, long-term relationships with our counterparts at SSA. The team recently received a Partnership Award from the State of Wisconsin SSA Office.

PCG has successfully enrolled tens of thousands of disabled individuals.

The following example, based on actual PCG client plan data, shows the impact of applying data-driven screening to identify and prioritize disabled members:

Data Driven Screening to Identify and Prioritize Disabled members

Our data analytics screening reduces the number of likely SSDIeligible members to 4,000 for a typical plan with 100,000 members. We outreach to these 4,000 members and, through our case interview screening process, are able to eliminate all but 1,400 members who are most likely to be eligible for SSDI/ Medicare benefits.

Financial Impact

The financial impact of transitioning disabled members to Medicare may be very significant. It is not uncommon for health plans to spend in excess of $100,000 annually for the types of members identified through our process. Assuming an average annual savings of $40,000, a plan like the one mentioned above could save more than $47 million per year:


1,400 applicants x 85% PCG allowance rate x $40,000 savings per member = $47M in annual savings


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More Information

For more information about PCG Health's Disability Determination & Medicaid Enrollment Consulting Services please contact us or 1-800-210-6113.