Want to look up a client's Medicare status, Medicaid status, or plan history – without opening yet another platform? We've got you covered.
Overview
Our eligibility lookup lets you pull a beneficiary's details directly from CMS – without leaving HealthSherpa Medicare.
Enter a client's info, and we'll return their Medicare & Medicaid eligibility status, current plan, prior enrollments, LIS status, and more.
The data auto-populates a new contact record, so you skip the manual data entry and start with verified information.
ℹ️ Coming very soon: run eligibility checks against existing contact records. 👀
How it works:
Enter the basics – MBI, first name, last name, and date of birth.
We check CMS – We query CMS for the client's Medicare details.
Review the results – See eligibility, current plan, prior enrollments, subsidies, and more – all on one screen.
Create the contact – One click saves everything to a new contact record.
Add the rest – phone, email, notes, etc can be filled out next.
Running a lookup
Start a new contact
Go to your Contacts tab and click Add contact. You'll see two options at the top – select Eligibility lookup.
Enter beneficiary details
Fill in MBI, name, date of birth, and click Check eligibility. If you see an error, try again, sometimes it takes try a few times.
Review results
Here's what you'll see:
Identity & address Name, date of birth, gender, and address – as recorded by CMS.
Part A & Part B effective dates, so you can confirm Original Medicare coverage.
Current plan The client's current Medicare plan – including plan name, CMS plan ID, plan type, and start date.
Prior enrollments Up to 10 enrollments, with CMS plan IDs and start/end dates.
Medicaid, D-SNP & LIS status badges appear for any active statuses:
Medicaid eligible – shown when the client has active Medicaid coverage.
D-SNP eligible – shown when the client qualifies for D-SNP plans.
LIS (Low-Income Subsidy) – with copayment level (e.g., "LIS Level 3")
Medicaid level lookup
If the eligibility check shows the client is Medicaid eligible, an additional section appears: Medicaid level lookup. This hits a separate state-level check to return the client's specific Medicaid category – QMB, SLMB, QMB+, SLMB+, QI, QDWI, or other.
How to use it
You'll see two fields:
Medicaid number
ZIP code
County
Enter the client's Medicaid number and click Check Medicaid level.
The Medicaid lookup endpoint doesn't always respond instantly. When you click Check Medicaid level, you'll see a spinner while we check. Behind that spinner, we're polling the state endpoint automatically — you don't need to do anything.
If we get a result, the spinner dismisses and the Medicaid level displays inline (e.g., "QMB," "SLMB+").
If the state endpoint doesn't respond after several attempts, we'll show a message: "Medicaid status couldn't be verified right now. You can try again, or proceed without it."
Note: Virginia does not support Medicaid eligibility checks at this time.
Create the contact
When you've reviewed the results, click Create contact & continue.
This saves everything to your account in one step:
A new contact record is created with all the CMS-sourced fields populated — name, DOB, gender, address, MBI, Part A/B dates, Medicaid status, LIS level, and more.
An enrollment record is created for the client's current plan — with plan name, CMS plan ID, plan type, and effective date.
Prior enrollments are written to the contact's notes field, with CMS plan IDs and date ranges.
You're then taken to the Edit Contact page, where you can add phone, email, and anything else. A toast will confirm: "Contact created. CMS eligibility details were saved."
What gets saved
Here's a quick summary of what's saved after you click Create contact & continue:
Data | Where it's saved |
Name, DOB, gender, address, MBI, Part A/B dates, Medicaid status, LIS level | Contact record |
Current plan (plan name, CMS plan ID, type, effective date) | Enrollment record, with source listed as CMS |
Prior enrollments (CMS plan IDs + date ranges) | A Notes entry on the contact |
Medicaid level (QMB, SLMB, etc.) | Contact record |
Activity log: Two entries are created – one for the contact creation (attributed to "CMS"), and one for any edits you make on the Edit Contact page (attributed to you). This separation means every field is traceable to its source.
Enrollment source label: The enrollment record created from eligibility lookup shows External (CMS) as the source, so you can distinguish it from manually created or imported enrollments.
Errors
If a lookup doesn't go through, you'll see an inline message explaining what happened. In most cases, you can just try again – sometimes it takes a few tries.
What you see | What to do |
"We couldn't complete the eligibility check. Please verify your MBI, date of birth, and name, then try again." | Double-check the fields you entered. The MBI, name, and DOB must match what CMS has on file.
|
"Eligibility check timed out." | Try again – this is usually temporary. |
"Service temporarily unavailable." | Try again – this is usually temporary. |
"This beneficiary does not appear Medicare-eligible per CMS." | The person may not be Medicare-eligible. Verify the MBI and try again, or proceed with manual entry. |
💡 Tip: We've seen occasional cases where the CMS endpoint returns an error on the first try but works fine on a retry with the same information. If you get an unexpected error, it's worth trying once more before switching to manual entry.
FAQ
Does this work for existing contacts? Not yet, but coming soon. Right now, eligibility lookup is available on the Add Contact page only — it creates a new contact from the CMS data. We're planning to bring this to existing contacts in a future release.
What if I already have this person as a contact? For now, the system doesn't check for duplicates. If you run a lookup for someone who already exists in your account, a second contact will be created. We recommend checking your contacts list first.
Can I edit the data that comes back from CMS? Yes. After the contact is created, you're taken to the Edit Contact page where every field is editable — both the CMS-populated fields and any empty ones. The enrollment record is also editable, just like any External enrollment.
Why are prior enrollments in the notes field instead of enrollment records? Current enrollment is added to your Enrollments records – but prior enrollments only come back with plan IDs and dates, not plan name or carrier, so we save them as a formatted note. We plan to map these to full plan records in a future release.
What does "External (CMS)" mean on an enrollment? It means the enrollment record was created from an eligibility lookup — the data came directly from CMS.
Is there a limit on how many lookups I can do? Yes — 20 per hour and 100 per day, per agent. There's also a limit of 5 lookups per hour for the same beneficiary. These limits keep the CMS endpoint reliable for everyone.
Why are my Medicaid eligibility results mixed? — Sometimes, the first check can say Medicaid eligible and the second check (the Medicaid level check) can say not Medicaid eligible. In general you should trust the second check — that's the one from the State and is more accurate about Medicaid. The first check is a federal check.
Questions? Contact support
You can chat with the AI bot anytime (in the bottom-right corner), email medicare-agents@healthsherpa.com, or call (855) 521-4984.