State Medicare Modernization Act (MMA) File of Dual Eligible Beneficiaries Q&A

What is the State MMA file of dually eligible beneficiaries?

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.”

However, federal regulations at 42 CFR 423.910 now require states, effective April 1, 2022, to submit files daily.

How does CMS use the data submitted on these files?

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.

Who sends the file?

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.

How frequently do states send the file?

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.

What is the value of a state submitting multiple files?

Submitting multiple files each month benefits states, beneficiaries, and providers by allowing:

State efficiencies

  • 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).

What steps does a state need to take to submit files more frequently?

The MAPD Help Desk provides technical system support to states for file exchanges. Contact the MAPD Help Desk at mapdhelp@cms.hhs.gov or 1-800-927-8069. Visit the MAPD Help Desk Web site at http://go.cms.gov/mapdhelpdesk

Who do I contact with questions about more frequent MMA file submissions?

Contact the CMS Medicare-Medicaid Coordination Office at MMCO_MMA@cms.hhs.gov to learn about more frequent MMA file submissions.

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