Adult Medicaid Admin. Letters

DMA ADMINISTRATIVE LETTER NO: 13-05, MEDICARE BUY-IN UPDATE

DATE: OCTOBER 21, 2005

SUBJECT: Medicare D and Buy-In

DISTRIBUTION: County Directors of Social Services

Medicaid Eligibility Supervisors

Medicaid Eligibility Staff

I. BACKGROUND

The Medicare Prescription Drug Program will be implemented effective January 1, 2006. Medicaid will no longer provide prescription coverage for recipients who have Medicare. It is imperative that EIS contain correct Medicare and Social Security data that matches data found on the State Online Query (SOLQ). If EIS data for a recipient that has Medicare does not match that of SOLQ, the recipient’s data will also be incorrect in the Medicare Drug Program files. This could impact his prescription coverage.

For applications and redeterminations, always use SOLQ data for verification of Medicare, recipient name (first, middle initial, last), date of birth, RSDI or Railroad Retirement Claim Number and/or Social Security Number. A “Z” appears in EIS when a DSS-8125 is keyed with a “Y” in the Medicare field until buy-in is completed. We have identified a number of cases that contain “Z’s” in the Medicare Indicator field in EIS. This indicator means that the individual’s buy-in status is unresolved. Follow procedures below to assure that EIS data is correct for existing cases.

II. PROCEDURES

A query has been created in Data Warehouse that will identify all individuals whose Medicare indicators are “Z” and the disposition date is prior to July 1, 2005. Each county must run the query for their county and review the identified cases to determine the correct Medicare status. The county must ensure that demographic information and claim number information in EIS matches SOLQ. Report your findings as indicated in C. below.

A. Running the Query

Designate an individual with access to Data Warehouse to run the query to identify individuals in your county with a Medicare indicator of “Z.” You may access the query by logging on to the main Data Warehouse screen.

• The query is located in Corporate Documents under the Category titled “State Sanctioned Work First and EIS Queries.”

• The query is titled “Medicare A or B is Z, enter co, Disp earlier than July 05.”

1. You must run the query twice to gather data separately for SSI and non-SSI cases

a. Enter county number in the screen and “y” or “n” for SSI.

b. Click on “Run Query.”

2. We recommend that you save the queries as Excel Spreadsheets.

a. Print the results from running the queries in “Landscape” format on legal size paper so that all fields can be viewed.

b. The spreadsheet can be sorted by district, etc.

B. Matching Data with SOLQ

Review SOLQ data for all recipients who appear on the queries. Refer to MA-2410, Medicare Enrollment and Buy-In, VII.D. for assistance. Information regarding effective dates of Medicare coverage is found on page 3 of the SOLQ. You must verify whether the individual has Medicare and that demographic information in SOLQ matches that contained in EIS.

1. Medicare

If the individual has Medicare there will be a date in the “START DATE” field under each type of insurance.

• Part A is listed as Health Insurance.

• Part B is listed as Supplemental Health Insurance.

a. If the individual has Medicare, and Buy-In has not taken place, follow procedures in MA-2410, Medicare Enrollment and Buy-In, VII.D. to complete and submit the DMA-5004, Buy-In Clerical Action (the Buy-In Indicator and monthly Buy-In “List of Actions” sent to counties by the Claims Analysis Section will indicate if the Buy-In process is already in effect.)

b. If the individual does not have Medicare, indicate this on your report under “Corrections.” The “Z” will be removed by DMA Claims Analysis Staff. Do not enter or delete anything in EIS.

2. Demographic Data

For all cases on the queries, ensure that the following data in EIS match information found on page one of SOLQ. This information needs to be corrected by December 1, 2005.

• First name, middle initial, last name

• Social Security Number

• Date of Birth

3. RSDI Claim Number

Do not change the RSDI Number for cases that appear on the queries. The Claims Analysis Section has performed a “clean up” match on RSDI numbers. Inform Claims Analysis (See C. below.) on your report if you disagree with the RSDI number on file. List what you think the RSDI Claim Number should be under “RSDI #” on the report to be mailed to the Claims Analysis Unit.

C. Reporting

Counties must report to DMA Claims Analysis only cases that need correction to the Medicare or RSDI fields. For reporting purposes, we recommend that you format information from the spreadsheets like the attached Example.

1. Non-SSI

Do not report changes that are made to the name, date of birth, or Social Security Number. List action taken or recommendation for the recipient under the column labeled CORRECTIONS.

2. SSI

County dss staff cannot change data on SSI cases. Please list under “Corrections” on your report the information that needs to be updated. Claims Analysis will contact the Social Security Administration to complete the changes.

No later than December 1, 2005 forward your report to:

Sara Harris

DMA Claims Analysis Unit

2501 Mail Service Center

Raleigh, NC 27699-2501

If you are unable to download the query to a spreadsheet or can’t format the spreadsheet like the example please:

• Write the changes on the query, or,

• Add an additional column to the spreadsheet and list the changes, and

• Send to the address above.

D. Additional Medicare Issues

Claims Analysis staff have requested that you be aware of the following concerns:

1. If SOLQ indicates that Medicare has terminated, do not take the RSDI claim number out of EIS. Buy-In staff are unable to terminate the premium payment if the RSDI claim number has been removed.

2. When entering an RSDI amount in EIS for a recipient who doesn’t have Medicare, do not enter a “Y” in the Medicare fields on the DSS-8125. Only enter “Y” when you have verified that an individual has Medicare. It is possible for a person to have RSDI and not be receiving Medicare yet.

3. Please follow procedures in MA-2410, Medicare Enrollment and Buy-In, X. B. 1. for aged aliens who do not have five years of residence in the United States. Enter “Z” in the RSDI claim number block on the DSS-8125 under individual data.

If you have any questions regarding this policy, please contact your Medicaid Program Representative.

L. Allen Dobson, Jr., MD

(This material was researched and written by Jon York, Field Staff Supervisor, Medicaid Eligibility Unit)