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.

You can run a lookup two ways:

When creating a new contact – the data auto-populates a new contact record, so you skip the manual data entry and start with verified information.
On an existing contact – compare what CMS has against what's on your contact record, and choose which updates to apply.

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 plans, subsidies, and more.
Create or update the contact – One click saves everything.

Running lookups on new contacts

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 can take try a few times.

Review results

Here's what you'll see:

Identity & address – Name, date of birth, gender, address – as reported by CMS.
Part A & Part B effective dates – so you can confirm Original Medicare coverage.
Current Medicare plan – plan name, CMS plan ID, plan type, 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")

Create the contact. When you've reviewed the results, click Create contact & continue. This saves everything in one step: a new contact record with all CMS-sourced fields, an enrollment record for the current plan, and prior enrollments written to the contact's notes. You're then taken to the Edit Contact page to add phone, email, and anything else.

Running lookups on existing contacts

Open any contact and click Eligibility lookup:

The lookup form

You'll arrive at the lookup form. The four fields are pre-filled from the contact record.

Reviewing the results

Instead of a plain results screen, you'll see a comparison table: what's on your contact record ("Current") side by side with what CMS returned ("From CMS").

Each row gets a status:

Status	What it means	What happens if applied
Match	Your record and CMS agree	Nothing – no change needed
Change	CMS has a different value than your record	Your value is replaced with the CMS value
New	Your record was empty; CMS has a value	The CMS value fills the empty field
Clear	Your record has a value; CMS returned nothing	The field on your record is cleared

You're in control of every update. Change, New, and Clear rows each have a checkbox (checked by default). Uncheck any row to keep what's on your record, rather than accept CMS's result – for example, if you know the client moved recently and your address is more current than CMS's.

If you like, use the Show matches toggle at the top of the table to hide matching rows and focus on just the differences.

Every applied change is recorded in the contact's Activity Log, attributed to "CMS," with the before-and-after values – so you can always see what changed.

Things to know

LIS level is shown for reference. If CMS reports LIS, you'll see the copayment level and dates under the LIS row. The Yes/No LIS status is saved to the contact; the level itself is informational.
Enrollments: if CMS returns a current plan that doesn't match any enrollment on the contact, a new enrollment record is created when you apply (source: External (CMS)). Existing enrollment records are not modified, to avoid creating duplicate records. Prior enrollments are added to the contact's Notes with each check.
Medicaid checks have nuances when checking existing contacts, see below.

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.

Enter the client's Medicaid number, ZIP, and county, and click Check Medicaid level.

The Medicaid lookup can a minute> When complete it shows the Medicaid level:

Notes:

If it shows an error, try again, sometimes it takes a few tries.
This requires a complete address on the record – city, state, ZIP, and county. If any of these are missing, the state endpoint returns an address error. Add the missing address fields to the Contact record and run the check again.
Virginia does not support Medicaid eligibility checks at this time.

If you don't see the Medicaid section

When checking existing contacts, the Medicaid section appears based on what's currently on your contact record – not on what CMS shows. Two situations:

If CMS says Medicaid eligible = Yes, but your record has No or blank: the Medicaid section won't appear on this check. Apply your updates (including the Medicaid eligible change), then run the eligibility lookup again – the section will appear on the second check.
Your record says Yes, but CMS says No: the section still appears. If you run the level check, the state will simply report the client isn't eligible.

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. If they match, then it often helps to just try the lookup again, sometimes 2 or 3 times.
"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

Can I edit the data that comes back from CMS? Yes, two ways. On an existing contact, uncheck any row in the comparison table to keep your value instead of CMS's. And after applying (or creating a new contact), every field remains editable on the Edit Contact page, including the enrollment record.

Why don't I see the Medicaid level lookup even though the check says Medicaid eligible? The section appears based on the Medicaid status already on your contact record. Apply your updates, then run the lookup again – it will appear on the next check. (See "Why you might not see the Medicaid section" above.)

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 – 50 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. We will considering upping these for AEP.

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.