Announcements

CMS Announcement: Disenrollment from Medicare Advantage and Prescription Drug Plans of Medicare Enrollees Who Are Incarcerated or Not Lawfully Present in the United States

On, November 2, 2021, CMS issued a memorandum to Medicare Advantage and Prescription Drug Plans to provide information about enrollment and disenrollment for individuals who are incarcerated or not lawfully present in the United States. On June 26, 2022, CMS plans to disenroll individuals in accordance with eligibility requirements codified in 42 CFR §§ 417.422, 422.50, and 423.30.

States will see these changes in the CMS MMA or TBQ response file they receive after that date.  States that have programs to align Medicaid with Medicare plan enrollment for dually eligible individuals may want to review CMS data for Medicare plan disenrollment, and going forward, for Medicare eligibility status on incarceration and lawful presence.  Key fields within the CMS response file include:

States can find the fields on the MMA Response File Detail layout in section 7.5 of the MAPD State User Guide (SUG):

Disenrollment from Medicare plans

  • Items 143-144 Beneficiary Managed Care (MCO) Enrollment Start/End Date
  • Item 145 Beneficiary MCO Number (contract level) (Occurrence 1)
  • Items 146-154 will display Occurrences 2-10
  • Item 155 Group Health Plan Enrollment Start Date (Occurrence 1)
  • Items 156-157 Plan Benefit Package (PBP) Enrollment Start/End Date (Occurrence 1)
  • Item 158 Plan Benefit Package Number
  • Item 159 Plan Benefit Package Coverage Type Code (Occurrence 1)
  • Items 160-168 will display PBP Enrollment Occurrences 2-10

Change in Medicare plan eligibility status

  • Item 237 Medicare Plan Ineligibility Due to Incarceration Start Date (Occurrence 1).
  • Items 274-291 will display Occurrences 2-10
  • Item 292 Medicare Plan Ineligibility Due to Not Lawful Presence Start Date (Occurrence 1)
  • Items 293-311 will display Occurrences 2-10

States can find the fields on the TBQ Response File Detail file layout, section 11.3 of the MAPD State User Guide (SUG):

Disenrollment from Medicare plans

  • Items 89-90 Beneficiary Managed Care Organization (MCO) Start/End Date (Occurrence 1)
  • Item 91 Beneficiary MCO contract number
  • Items 92-100 will display Managed Care Organization Occurrences 2-10
  • Item 101 Group Health Plan Enrollment Effective Date
  • Items 102-103 Plan Benefit Package Start/End Date
  • Item 104 Plan Benefit Package Number
  • Item 105 Plan Benefit Package Coverage Type Code
  • Items 106-114 will display Plan Benefit Package Election Occurrences 2-10

Change in Medicare plan eligibility status

  • Items 184-185 Medicare Plan Ineligibility Due to Incarceration start/end Date (Occurrence 1)
  • Items 218-235 will display Occurrences 2-10.
  • Items 236-255 Medicare Plan Ineligibility Due to Not Lawful Presence Start (Occurrences 1-10)

Please contact the Medicare-Medicaid Coordination Office (MMCO) here with questions.

Posted On:

April 27, 2021

Announcing CMS FY2022 IPPS/LTCH PPS proposed rule (CMS-1752-P); Medicaid Provider Enrollment and Medicare Cost-sharing for Dually Eligible Beneficiaries

On April 27, 2021, CMS issued the FY2022 IPPS/LTCH PPS proposed rule (CMS-1752-P). I am writing to flag for you one proposal that aims to improve state processing of Medicare cost sharing claims for services provided to dually eligible individuals. Specifically, this proposal would require state Medicaid agencies to allow enrollment of all Medicare-enrolled providers and suppliers for purposes of processing claims for Medicare cost sharing on services for dually eligible individuals. If finalized, this proposal will improve compliance with current statute and reduce burden for providers related to crossover claims submission and the claiming of Medicare bad debt.

Additionally, we are requesting information from stakeholders on instances where states determine their cost-sharing liability for a Medicare service by applying the Medicaid payment and coverage rules for the service as if the service (rather than the cost-sharing) were being paid by Medicaid.

The NPRM is available at https://www.federalregister.gov/public-inspection/2021-08888/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the. For the provision specific to dually eligible individuals, please see Section X (“Medicaid Enrollment of Medicare Providers and Suppliers for Purposes of Processing Claims for Cost-Sharing for Services Furnished to Dually Eligible Beneficiaries”) and proposed changes to regulatory text in 42 CFR 455.10. As always, we encourage you to review closely and comment. The comment period closes on June 28, 2021.

Posted On:

April 7, 2021

Highlighting Available Medicare Claims Data for COVID-19 Vaccination Coordination

To identify via Medicare claims data those dually eligible individuals with COVID-19 vaccination billed to Medicare within your state, please use the following steps.

For enhanced Coordination of Benefits Agreement (eCOBA) file:

Please use the above HCPCS codes to identify the COVID-19 vaccine claims within your eCOBA file (Medicaid COBA ID range 79000-7999; Medicaid MCO COBA ID range 77000-78999).

  1. Run a query on your eCOBA file using the HCPCS codes found in the table below.
  2. After you have identified the individuals who have the above HCPCS codes associated with their records, use the MBI number associated with the record within your eCOBA file to identify the beneficiary.
  3. As you have identified the claims for dually eligible individuals associated with a vaccine that requires two doses, you can flag their MBI to ensure you capture the claim for the second dose administration.
  4. We recommend performing additional data analysis to link the COVID-19 vaccination claims demographic data to assess health disparities, such as by race/ethnicity, disability status, or geography.

For Monthly Part A and B data set:

  1. Identify your Medicare Part B Carrier Claim File. Specifically, you will need the Carrier Line Data.
  2. Run a query on your Carrier Line Data Set on the HCPCS codes found in the table below.
  3. After you have identified the individuals who have the above HCPCS codes associated with their records, use one of the crosswalk files provided to you with your monthly Part A and B data (BENE_ID to MBI, BENE_ID to SSN, BENE_ID to HICN) to identify the beneficiary.
  4. As you have identified the claims for dually eligible individuals associated with a vaccine that requires two doses, you can flag their BENE_ID to ensure you capture the claim for the second dose administration.
  5. We recommend performing additional data analysis to link the COVID-19 vaccination claims demographic data to assess health disparities, such as by race/ethnicity, disability status, or geography.
HCPCS Code(s) (Vaccine Code) Vaccine Administration Codes Manufacturer Vaccine Names NDC 10/NCD11 Codes
91300 0001A (1st Dose) Pfizer, Inc Pfizer-BioNTech COVID-19 Vaccine 59267-1000-1 59267-1000-01
91300 0002A (2nd Dose) Pfizer, Inc Pfizer-BioNTech COVID-19 Vaccine 59267-1000-1 59267-1000-01
91301 0011A (1st Dose) Moderna, Inc Moderna COVID-19 Vaccine 80777-273-10 80777-0273-10
91301 0012A (2nd Dose) Moderna, Inc Moderna COVID-19 Vaccine 80777-273-10 80777-0273-10
91302 0021A (1st Dose) AstraZeneca AstraZeneca COVID-19 Vaccine 0310-1222-10 00310-1222-10
91302 0022A (2nd Dose) AstraZeneca AstraZeneca COVID-19 Vaccine 0310-1222-10 00310-1222-10
91303 0031A (Single Dose) Janssen Janssen COVID-19 Vaccine 59676-580-05 59676-0580-05

Reference: https://www.ama-assn.org/find-covid-19-vaccine-codes

Note: This Medicare COVID-19 vaccination data only applies to those dually eligible beneficiaries for whom Medicare received and adjudicated a claim. This data does not include any dually eligible beneficiary who received a COVID-19 vaccination that was not billed to Medicare.

If your state currently does not receive either of the files discussed above, but are interested in receiving these data sets, please contact the SDRC at SDRC@EconometricaInc.com.

Posted On:

December 23, 2019

CMS Informational Bulletin and Tip Sheet for OTP Providers on Part B Medicare Opioid Treatment Program (OTP) Benefit for Dually Eligible Individuals

On Tuesday, December 17, 2019, the Centers for Medicare & Medicaid Services (CMS) issued an informational bulletin to provide guidance to state Medicaid agencies regarding coverage changes for dually eligible beneficiaries receiving opioid treatment services. Starting on Wednesday, January 1, 2020, Medicare will begin paying for opioid treatment programs (OTPs) through bundled payments for opioid use disorder (OUD) treatment services, including medication-assisted treatment (MAT) medications, toxicology testing, and counseling. In order to be paid by Medicare, OTP providers will need to be enrolled as a Medicare provider. In an effort to prevent any disruption in OTP treatment for dually eligible beneficiaries, CMS is providing background information on provider enrollment and clarifying options for states on coordination of benefits/third party liability under Medicaid as outlined at https://www.medicaid.gov/federal-policy-guidance/downloads/cib121719.pdf.

Additionally, on Thursday, December 12, 2019, CMS released a tip sheet for Opioid Treatment Program (OTP) Providers Serving Dually Eligible Individuals: State Coverage of the Medicare Part B Deductible, which can be viewed at https://www.cms.gov/files/document/otp-crossover-tip-sheet.

Posted On:

December 23, 2019

State Payment of Medicare Premiums Manual Update

On Friday, December 13, 2019, the Centers for Medicare & Medicaid Services (CMS) released a draft Manual for State Payment of Medicare Premiums (formerly called “State Buy-in Manual”) to states and other stakeholders for review and comment. The manual update is part of CMS’ Better Care for Dual Eligible Individuals Strategic Initiative aimed at improving quality, reducing costs, and improving customer experiences. The draft manual and instructions for commenting are available at: https://www.cms.gov/medicare-medicaid-coordination/medicare-medicaid-coordination-office/state-payment-medicare-premiums.

 

We are welcoming comments through 5:00 p.m. EST on Saturday, February 29, 2020.

Posted On:

September 10, 2019

2017 Medicare Historic Parts A and B and Assessments Data Available

Calendar Year 2017 Medicare Historic Parts A and B and Assessments data from the Chronic Conditions Warehouse (CCW) have been final-actioned and are now available for request.

Posted On:

October 25, 2018

Resources on Opioid Use Disorder Among Dual Eligible Beneficiaries

Beneficiaries dually eligible for Medicare and Medicaid Services may be particularly vulnerable to opioid addiction or misuse. In an October 2016 memo, the Centers for Medicare & Medicaid (CMS) estimated that these beneficiaries have significantly higher rates of co-occurring substance use disorders and chronic pain relative to Medicare-only beneficiaries or Medicaid-only adults with disabilities. Following are two new resources on opioid use disorder among dually eligible individuals:

Data Brief on National Trends in High-Dose Chronic Opioid Utilization Among Dually Eligible and Medicare-Only Beneficiaries (2006-2015)

This data brief provides a baseline understanding of high-dose chronic (HDC) prescription opioid use among dually eligible beneficiaries over the 10-year period from 2006 to 2015. The brief underscores that dually eligible individuals receive prescription opioids at higher rates than those with Medicare-only and that these differences are driven mainly by disability. For example, in 2015, while 10.4% of dually eligible and 4.9% of Medicare-only opioid-using beneficiaries were prescribed opioids at the high dose chronic level. Among those qualifying for Medicare by disability, these rates were 13.4% and 14.7%, respectively. This data brief is available on our MMCO analytics webpage at https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/Analytics.html.

New Opioid Use Indicators in the Chronic Conditions Warehouse

CMS has created four new Chronic Conditions Data Warehouse (CCW) indicators to promote research on opioid use disorder (OUD).

    1. An overarching indicator of OUD.
    2. Diagnosis and procedure-code bases for OUD.
    3. Opioid-related hospitalizations or emergency department visits.
    4. Use of medication-assisted treatment (MAT).

The new indicators use algorithms by developed by experts and vetted during a public comment period. As with all other CCW indicators, the OUD-related indicators facilitate research as well as promote measurement quality and consistency. More information can be found at https://www.ccwdata.org/web/guest/condition-categories.

Have any questions or concerns? Please contact the SDRC Team.