Since 2005, states have been submitting files at least monthly to CMS to identify all dually eligible beneficiaries. This includes full benefit and partial benefit dually eligible beneficiaries (i.e., those who get Medicaid help with Medicare premiums, and often for cost-sharing). The file is called the “MMA File” (after the Medicare Prescription Drug, Improvement and Modernization Act of 2003), but occasionally referred to as the “State Phasedown file.”
The monthly files support the following program needs for CMS:
- Auto-enrolling full-benefit dually eligible beneficiaries into Medicare drug plans.
- Deeming full and partial benefit dually eligible beneficiaries automatically eligible for the Medicare Part D Low Income Subsidy (LIS, sometimes called Extra Help).
- Determining monthly phase-down payment amounts due from states.
- Risk-adjusting capitation payments to Medicare Advantage plans.
- In Original Medicare, identifying Qualified Medicare Beneficiary (QMB) status to alert those individuals and the providers who serve them that they are not liable for Medicare cost sharing for Medicare Parts A and B services.
Medicaid agencies for each of the 50 states and the District of Columbia (hereafter referred to as “states”) submit files identifying all known dually eligible beneficiaries.
States must submit at least one file each month. However, states have the option to submit multiple MMA files throughout the month (up to one per day). Most states submit at least weekly, and CMS encourages states to submit as frequently as possible. States that submit multiple times per month submit a large initial file including the bulk of enrollments for the reporting month, then smaller incremental files providing updates for changes in dual eligibility status (additions, deletions, or changes). States should not submit multiple full replacement files as CMS will not be able to effectively process the files.
Submitting multiple files each month benefits states, beneficiaries, and providers by allowing:
- Faster transition to Medicare drug coverage. The sooner a dual eligible beneficiary transitioning from Medicaid drug coverage to Medicare Part D drug coverage gets auto-enrolled into a Medicare drug plan, the fewer claims that are paid erroneously by the state and the fewer they have to recoup from pharmacists (who then have the burden of reaching out to reconcile with the new Part D plan).
- Faster turnaround to Medicare as primary for other services. More frequent file submission increases the speed of identifying new Medicare Parts A and B enrollment, so states can more quickly implement edits so Medicaid doesn’t cover those Medicare services. This also has the benefit of reducing oversight risks related to audits on third-party liability.
- Streamline error identification/resolution. A general issue is that if there is some data error (e.g., transposed numbers) and some back and forth is needed to straighten things out, there is a better chance of getting it fixed before the start of the next month if files are transferred more frequently.
- Supports states promoting enrollment in integrated care. Particularly for beneficiaries who are newly dually eligible, more frequent data exchange helps states facilitate enrollment into integrated products earlier (Dual Eligible Special Needs Plans, and other Medicare Advantage plans and Medicare-Medicaid plans).
Beneficiary access to care
- Faster access to Medicare subsidies. Dual eligibility status on the MMA file prompts CMS to deem individuals automatically eligible for the Medicare Part D Low Income Subsidy (LIS), make changes to LIS status (e.g., prompted by a move to a nursing facility or HCBS), and auto-enroll them into Medicare prescription drug coverage back to the start of dual eligibility status. This reduces beneficiary cost-sharing and improves access to Medicare-covered medications.
- More efficient communication to Qualified Medicare Beneficiaries (QMB) regarding zero liability for Medicare Part A and B cost sharing, and protections from providers billing them for it. A lag in data could cause confusion for the QMB, as the Medicare Summary Notice they receive would show they are liable and can be billed. In the worst cases, the beneficiary may limit the need for services due to outstanding financial obligation to the provider.
Provider burden reductions
- Supports Medicare provider and health plan compliance with restrictions on billing QMBs for cost-sharing for services covered by Medicare Parts A and B. CMS notifies fee-for-service (FFS) providers of QMB status via its eligibility query (HETS) and claims processing (provider remittance advice) systems, based on data submitted on the MMA file. Lags in data could cause confusion on the ground for providers and beneficiaries, with a possible uptick in inquiries to the state. For example, delays in data will cause problems for those new to QMB.
- Alleviate the burden on pharmacists. The sooner a dual eligible beneficiary transitioning from Medicaid drug coverage to Medicare Part D drug coverage gets enrolled into a Medicare drug plan, the fewer claims that are paid erroneously by the state and the fewer they have to recoup from pharmacists (who then have the burden of reaching out to reconcile with the new Part D plan).
The submission of multiple MMA files per month follows the same methodology for submission and the same file-naming conventions as the submission of a single monthly file. The MAPD Help Desk provides technical system support to states for file exchanges. Contact the MAPD Help Desk at firstname.lastname@example.org or 1-800-927-8069. Visit the MAPD Help Desk Web site at http://go.cms.gov/mapdhelpdesk.
The MAPD State User Guide has additional information pertinent to the content of multiple monthly files. The latest version of this guide can be found at: https://www.cms.gov/ResearchStatistics-Data-and-Systems/CMS-Information-Technology/mapdhelpdesk/MAPD-State-UserGuide.html. Sections 4.1, 4.3 and 5.1 are especially relevant.
The following are the most important guidelines for submitting multiple files:
- A state has the option to submit a single monthly MMA file including all known dual eligible beneficiaries, or multiple MMA files throughout the month (up to one per day). Multiple files are intended to give a state the opportunity to provide current information on updated dual eligibility status. Multiple submittals should represent only those beneficiary person-months with changes in status. States that opt to submit more frequently must submit a large initial file including the all known dual eligible beneficiaries for the reporting month, and smaller incremental files providing updates for changes in dual eligibility status (additions, deletions, or changes).
- A state may also submit multiple files throughout the month each consisting only of partial enrollments, as long as the accrual of all those file submissions would deliver, by month’s end, a complete representation of all dual eligible enrollments in the state for that month.
- A state should not submit multiple full replacement files as CMS will not be able to effectively process the files.
- If multiple records having the same Eligibility Month/Year are submitted for the same beneficiary in a single file or multiple file submittals, the last record submitted for that beneficiary shall be used to determine the final effect on the Phase-Down count.
- CMS processes the MMA files in the order the files are received.