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Navigating the Buy-in

Navigating the Buy-in. October 1, 2009. Situation #1 Nancy. Nancy is turning 65 next month. She will receive $867.00 in RSDI starting next month. Should this recipient Buy-in for Part A? No Yes If yes what date? __________ Should this recipient Buy-in for Part B?

gwendolyn-hoffman
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Navigating the Buy-in

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  1. Navigating the Buy-in October 1, 2009

  2. Situation #1 Nancy Nancy is turning 65 next month. She will receive $867.00 in RSDI starting next month. Should this recipient Buy-in for Part A? No Yes If yes what date? __________ Should this recipient Buy-in for Part B? No Yes If yes what date? __________

  3. Answer: Situation #1 Nancy Nancy is turning 65 next month. She will receive $867.00 in RSDI starting next month. Should this recipient Buy-in for Part A? No, it is free. Should this recipient Buy-in for Part B? Yes, 11/01/09.

  4. Situation #2 Carl Carl is 58 years old and receives SSI of $674.00 for disability and MSA of $81.00. Should this recipient Buy-in for Part A? No Yes If yes what date? __________ Should this recipient Buy-in for Part B? No Yes If yes what date? __________

  5. Answer: Situation #2 Carl Carl is 58 years old and receives SSI of $674.00 for disability and MSA of $81.00. Should this recipient Buy-in for Part A? No, he does not have Medicare eligibility. Should this recipient Buy-in for Part B? No, he does not have Medicare eligibility.

  6. Situation #3 Lenny Lenny is 32 and receives RSDI of $400.00 and SSI of $294.00. His Medicare began 9/1/09. Should this recipient Buy-in for Part A? No Yes If yes what date? __________ Should this recipient Buy-in for Part B? No Yes If yes what date? __________

  7. Answer: Situation #3 Lenny Lenny is 32 and receives RSDI of $400.00 and SSI of $294.00. His Medicare began 9/1/09. Should this recipient Buy-in for Part A? No, it is free. Should this recipient Buy-in for Part B? Yes, 9/01/09. Lenny is categorically eligible for the buy-in due to SSI and MA even if the worker does not open QMB.

  8. What is the Buy-in? The Buy-in is a 2-part data exchange between DHS and CMS that pays Medicare premiums for eligible individuals. • Part 1: DHS sends data via MMIS to CMS, to communicate which MHCP recipients appear eligible, or have lost eligibility, to have their Medicare A or B premiums paid by the State of Minnesota. • Part 2: CMS responds. They will either accept, reject, or modify the DHS request.

  9. MAXIS and the Buy-in MAXIS has to have the correct information before the buy-in process can work correctly in MMIS. • STAT UNEA must have the income start date • STAT MEDI must be entered including the Medicare claim number • Be approved on a Medicare Savings Program (MSP) in Health Care Eligibility

  10. Buy-in Eligibility To be eligible for the Buy-in a person must qualify for Medicare and: • Be enrolled in an MSP • Be enrolled in MA, entitled to premium-free Medicare Part A, and be enrolled in one of the following programs: • Minnesota Supplemental Aid (MSA) • Minnesota Family Investment Program (MFIP) • 1619(a) or 1619(b) SSI status • IV-E Adoption Assistance • IV-E Foster Care • Group Residential Housing (GRH)

  11. Buy-in Referral Refer people not enrolled in Medicare who are eligible for the buy-in to SSA. • Check TPQY in MAXIS to ensure there are no discrepancies in the person’s name or DOB • Complete and send DHS-3439 Medicare Buy-in Referral Letter • Allow 60 days to apply for Medicare and return confirmation portion of the referral letter • Update STAT PBEN in MAXIS and track return of letter on DAIL/TIKL • Process MSP eligibility upon receipt of the letter

  12. Previous Medicare Entitlement Do not refer people who have Part A only or Part B only or who have had Medicare previously. They are already known to SSA and do not need to reapply for Medicare to have entitlement reestablished.

  13. Not Entitled to Premium-Free Part A • People who qualify for Medicare, but are not entitled to premium-free Medicare Part A, including people who receive SSI only who are age 65 or older, must be enrolled in QMB to participate in the buy-in. QMB will pay the Medicare Part A premium, the Medicare Part B premium, and other Parts A and B cost sharing. • Do not approve retroactive SLMB eligibility for any enrollee who must pay a premium to get Medicare Part A, even if the referral form shows a Medicare begin date in a past or current month. Approve prospective QMB eligibility only for these enrollees.

  14. Accrete/Delete The communication from DHS (via MMIS) to CMS is called Accrete/Delete. • This process runs 8 working days from the end of the month • Everyone who has active MHCP is evaluated to see if they have become eligible, remain eligible, or have lost eligibility for the buy-in

  15. Accrete/Delete – October 2009 The MAXIS/MEC2/MMIS Production calendar is available on SIR.

  16. Buy-in Apply The CMS response to Accrete/Delete is called Buy-in Apply • Buy-in Apply runs on the 6th working day of the month (roughly 3 weeks after Accrete/Delete). • Buy-in Apply may also contain CMS-initiated data that can impact buy-in such as: • SSI participation • Medicare begin or end dates • Medicare ID number changes

  17. Buy-in Apply for November 2009 The MAXIS/MEC2/MMIS Production calendar is available on SIR.

  18. Buy-in for Part A • Must have Medicare ID# and Part A participation dates on RMCR, which can be interfaced from STAT/MEDI. • Requires program eligibility of QMB or QWD. • Must not have an entitlement/non-entitlement code of “E” on RBUY. • The Part A calculated accrete request date will be the later of RELG or RMCR dates.

  19. Part A Information onRMCR and RBUY NEXT: RSVL 10/20/08 10:49:16 MMIS RECIP MEDICARE-RMCR TILMM02 10/16/08 PWMW134 01234567 12/18/1933 * BUYIN BETTY X * MEDICARE ID: 333224444M ********************************** RSN: * - - - - - - - - - - - - M E D I C A R E P A R T A - - - - - - - - - - - - MEDICARE PART A BENEFITS EXHAUSTED (Y/N): DATE: BEGIN DATE END DATE SRC PPHP (Y/N) BEGIN DATE END DATE SRC PPHP (Y/N) 07/01/08 99/99/99 M * NEXT: RBYB 10/20/08 11:16:44 MMIS RECIP BUYIN-RBUY TILMM02 10/16/08 PWMW133 01234567 12/18/1933 * BUYIN BETTY X * MEDICARE ID: 333224444M ********************************** ENTITLE/NON-ENTITLE: Y PART (A) ACCRETE REQUEST DATE: ACCRETE DATE: PART (A) DELETE REQUEST DATE: DELETE DATE: --------------------------BUYIN MONTHLY TRANSACTIONS--------------------------- TXN TXN SUB ACCRETE DELETE ----- PREMIUM ------ DATE CODE CODE DATE DATE AMOUNT DATE

  20. Buy-in for Part B • Must have Medicare ID# and Part B participation dates on RMCR, which can be interfaced from STAT/MEDI • Program eligibility under QMB or SLMB (including QI-1) or • Categorical eligibility of • MA with eligibility types 09, 15, 16, 25 or • Other MA with “M” indicator (MFIP) or • Other MA with MSA/GRH or SSI start dates on RMSC

  21. Part B Information onRMCR and RMSC NEXT: RSVL 10/20/08 10:49:16 MMIS RECIP MEDICARE-RMCR TILMM02 10/16/08 PWMW134 01234567 12/18/1933 * BUYIN BETTY X * MEDICARE ID: 333224444M ********************************** RSN: * - - - - - - - - - - - - M E D I C A R E P A R T B - - - - - - - - - - - - BEGIN DATE END DATE SRC PPHP (Y/N) BEGIN DATE END DATE SRC PPHP (Y/N) 07/01/08 99/99/99 M * ENTER---PF1---PF2---PF3---PF4---PF5---PF6---PF7---PF8---PF9---PF10---PF11--PF12 PAGE S/EXT N/EXT OOPS HELP NEXT: RHCI 10/20/08 11:34:48 MMIS RECIPIENT INFO-RMSC TILMM02 10/16/08 PWMW12M 01234567 12/18/1933 * BUYIN BETTY X * ********************************** - - - - M I S C E L L A N E O U S - - - - SSI BEGIN DATE: 08/01/2005 SSI END DATE: 99/99/9999 RSDI INCOME (Y/N): RAILROAD INCOME(Y/N): RSDI BEGIN DATE: RSDI END DATE: MSA/GRH GRANT BEG DATE: 12/01/2007 MSA/GRH GRANT END DATE: 99/99/9999 MFIP BEGIN DATE: MFIP END DATE: PREGNANCY BEGIN DATE: PREGNANCY END DATE:

  22. Determining the Part B Accrete Request Date The Medicare begin date is compared to RELG begin date and the later of the 2 dates is remembered as DATE 1. For categorical buy-in, further date checking is required. The MSA/GRH date is compared to SSI date on RMSC and the earlier date is remembered as DATE 2. The Part B calculated accrete request date will be the later of DATES 1 and 2.

  23. Calculating DATE 1 In this example DATE 1 would be 06/01/08 NEXT: RIDS 06/16/08 09:26:24 MMIS ELIGIBILITY-RELG TILSN83 04/24/05 PWMW127 00000000 00/00/0000 * SMITH SAM S * ********************************** - - - - - - - - - - - - - - E L I G I B I L I T Y - - - - - - - - - - - - - - 01 PRG: MA ELIG TY: EX CASE: 00000000 ELIG BEGIN: 01/01/08 ELIG END: 99/99/99 CFR: 018 STATUS: A REASON: 99 STATUS DATE: 01/03/08 DATE ADDED: 01/03/08 INDICATOR: N APPL DT: 01/01/08 NEXT: RSVL 06/16/08 09:26:52 MMIS RECIP MEDICARE-RMCR TILSN83 4/24/05PWMW134 00000000 00/00/0000 * SMITH SAM S * MEDICARE ID: 123456789A ********************************** RSN: * - - - - - - - - - - - - M E D I C A R E P A R T B - - - - - - - - - - - - MEDICARE PART B BENEFITS EXHAUSTED (Y/N): DATE: BEGIN DATE END DATE SRC PPHP (Y/N) BEGIN DATE END DATE SRC PPHP (Y/N) 06/01/08 99/99/99 F

  24. Calculating DATE 2 In this example DATE 2 would be 01/01/08 NEXT: RHCI 06/16/08 09:43:50 MMIS RECIPIENT INFO-RMSC TILSN83 04/24/05 PWMW12M 00000000 00/00/0000 * SMITH SAM S * ********************************** - - - - M I S C E L L A N E O U S - - - - SSI BEGIN DATE: 03/01/08 SSI END DATE: 99/99/99 RSDI INCOME (Y/N): RAILROAD INCOME(Y/N): RSDI BEGIN DATE: RSDI END DATE: MSA/GRH GRANT BEG DATE: 01/01/08 MSA/GRH GRANT END DATE: MFIP BEGIN DATE: MFIP END DATE: PREGNANCY BEGIN DATE: PREGNANCY END DATE:

  25. Determining the Part B Accrete Request Date DATE 1 and DATE 2 are now compared to determine the accrete request date In this example: • DATE 1 is 06/01/08 (Medicare begin date) • DATE 2 is 01/01/08 (SSI begin date) DATE 1 is the later of those 2 dates, so the Part B accrete request date is calculated to be 06/01/08.

  26. Determining the Accrete Request Date – Part A or B The next step in determining the accretion date is checking whether buy-in previously existed. If so, the new accrete request date must be after the prior period. NEXT: RBYD 06/16/08 09:02:16 MMIS RECIP BUYIN-RBYB TILSN83 04/24/05 PWMW133 00000000 00/00/0000 * SMITH SAM S * MEDICARE ID: 123456789A ********************************** ENTITLE/NON-ENTITLE: * PART (B) ACCRETE REQUEST DATE: ACCRETE DATE: 06/01/05 PART (B) DELETE REQUEST DATE: DELETE DATE: 06/30/08 --------------------------BUYIN MONTHLY TRANSACTIONS------------------------ TXN TXN MCARE ACCRETE DELETE ----- PREMIUM --- DATE CODE PART DATE DATE AMOUNT DATE The calculated accrete request date was 06/01/08. In this situation the actual accrete request date sent to CMS would be 07/01/08.

  27. Determining the Accrete Request Date – Part A or B • The accrete request date is systematically limited to 6 months retroactive to the current month. • For example, if there is a delayed eligibility determination and the begin date is more than 6 months in the past, the buy-in start date would be limited to 6 months ago. • Manual requests allow for buy-in to cover the period earlier than 6 months ago. MMIS User Services can key these requests.

  28. Situation #4 Trisha Trisha is 39 years old and receives RSDI of $1000.00 per month for disability starting 11/1/06. She has Medicare Part A that began 11/1/08 and she refused Medicare Part B when it was offered in 11/1/08. She came in today to apply for Health Care programs and is eligible for MA with a Spenddown effective 9/1/09. She has opted not to apply her Medicare premium to her Spenddown. Should this recipient Buy-in for Part A? No Yes If yes what date? __________ Should this recipient Buy-in for Part B? No Yes If yes what date? __________

  29. Answer: Situation #4 Trisha Trisha is 39 years old and receives RSDI of $1000.00 per month for disability starting 11/1/06. She has Medicare Part A that began 11/1/08 and she refused Medicare Part B when it was offered in 11/1/08. She came in today to apply for Health Care programs and is eligible for MA with a Spenddown effective 9/1/09. She has opted not to apply her Medicare premium to her Spenddown. Should this recipient Buy-in for Part A? No, it is free. Should this recipient Buy-in for Part B? Technically Yes she should buy-in for Part B 9/1/09, however there are no Part B begin dates on RMCR so she will not be picked up on the buy-in until there are dates. This panel interfaces from the STAT MEDI panel.

  30. Situation #5 Joe Joe is 32 and receives RSDI in the amount of $420.00 that began 9/1/07 and SSI in the amount of $274.00 that began 8/1/07 for disability. He is Medicare eligible beginning 9/1/09. He applied for Health Care programs on 10/1/09. He is eligible for MA 10/1/09 as he did not request retroactive coverage. Should this recipient Buy-in for Part A? No Yes If yes what date? __________ Should this recipient Buy-in for Part B? No Yes If yes what date? __________

  31. Answer: Situation #5 Joe Joe is 32 and receives RSDI in the amount of $420.00 that began 9/1/07 and SSI in the amount of $274.00 that began 8/1/07 for disability. He is Medicare eligible beginning 9/1/09. He applied for Health Care programs on 10/1/09. He is eligible for MA 10/1/09 as he did not request retroactive coverage. Should this recipient Buy-in for Part A? No, it is free. Should this recipient Buy-in for Part B? Yes 10/01/09 if picked up by the Categorical Buy-in due to the receipt of SSI with MA. 09/01/09 if opened on a MSP in MAXIS and coded on RELG in MMIS.

  32. Determining Part A Delete Date • Medicare end date is populated on RMCR or • Program eligibility has ended on RELG or • Entitle/Non-entitle code of “E” for Part A received The delete date will be the eligibility or Medicare end date or the end of the previous month in the case of the “E” coding.

  33. Determining Part B Delete Date • Medicare end date is populated on RMCR or • Program eligibility has ended on RELG or • Categorical eligibility has ended on RELG or RMSC (elig type, “M” Indicator, SSI, MSA/GRH) The delete date will be the eligibility/Medicare end date, or the end of last month.

  34. Accrete/Delete Request Dates RBUY and RBYB each have accrete and delete request date fields to indicate whether Accrete/Delete has determined a change in buy-in status or whether a manual request has been keyed: NEXT: RBYB 06/19/08 08:31:37 MMIS RECIP BUYIN-RBUY WMW1740 06/15/06 PWMW133 00000000 03/08/1937 * SMITH SAM R * MEDICARE ID: 123456789A ********************************** ENTITLE/NON-ENTITLE: Y PART (A) ACCRETE REQUEST DATE: 06/01/08 ACCRETE DATE: PART (A) DELETE REQUEST DATE: DELETE DATE:

  35. RBUY after Buy-in Apply NEXT: RBYD 06/16/08 09:02:16 MMIS RECIP BUYIN-RBUY TILSN83 00000000 00/00/0000 * PIPER PETER R * MEDICARE ID: 123456789A ********************************** ENTITLE/NON-ENTITLE: * PART (A) ACCRETE REQUEST DATE: ACCRETE DATE: 09/01/08 PART (A) DELETE REQUEST DATE: DELETE DATE: 99/99/99 --------------------------BUYIN MONTHLY TRANSACTIONS--------------------------- TXN TXN SUB ACCRETE DELETE ----- PREMIUM ------ DATE CODE CODE DATE DATE AMOUNT DATE 10/01/08 1161 09/01/08 846.00 09/01/08

  36. Basics of Buy-In TXN Codes The MMIS User Manual has a complete list of Buy-In related transactions and Worker Messages, along with guidelines for worker action

  37. Basics of Buy-In TXN Codes Accrete/Delete transaction codes The txn codes we send to CMS do not appear on RBUY/RBYB but are useful to know in relation to the response codes • 51 = delete request • 53 = delete request due to death • 61 = accrete request • 75 = simultaneous accrete/delete request • 99 = informational

  38. Basics of Buy-In TXN Codes When an accrete/delete transaction is accepted by CMS we will get these response codes • 1161 = CMS accepted an accrete request • 1751 = CMS accepted a delete request • 1753 = CMS accepted a delete request due to DOD When an accrete/delete transaction is rejected by CMS we will get these response codes: • 2051, 2053 = CMS rejects deletion request • 2161, 2175 = CMS rejects an accretion request

  39. Basics of Buy-In TXN Codes CMS-initiated transactions: • 41 = ongoing buy-in • 14, 15 = CMS reports Medicare entitlement ended • 16 = CMS reports a DOD • 1728 = CMS reports potential residence outside of Minnesota • 44 = Subsidy for Medicare Part B premium was received by CMS • 45 = Subsidy for Medicare Part B premium has ended

  40. Navigating the Buy-In Higher Priority Worker Messages

  41. Buy-In Worker Messages BUY-IN ACCRETION REJECTED FOR PART (A or B). REASON CODE (A, B, C, D, or E). REVIEW • Txn Code: 2161 • Definition: Accrete request was rejected due to MMIS/CMS discrepancies • MMIS: creates buy-in occur span with attempted accrete date and removes Accrete Request Date • Action: depends on reason code • Why Important: If enrollee is only Medicare eligible based on premium payment, enrollment in Medicare A and B is delayed until rejection is resolved.

  42. Buy-In Worker Messages • A: No match to Medicare ID# on the Electronic Data Base (EDB). Check BENDEX or send new TPQY. • B: Name, DOB, or sex code discrepancy between MMIS and EDB. Verify accuracy and update MAXIS/MMIS accordingly. • C for Pt A: Part A is free, or person does not have Part A. Verify Part A dates, and update MAXIS/MMIS accordingly. • C for Pt B: Accrete request is based on QM or SL and EDB shows no Part A coverage. Confirm Pt A eligibility (BENDEX, TPQY). If recipient is not eligible, close QM or SL.

  43. Buy-In Worker Messages • D for Pt A: no record of Pt B buy-in, which is required before Pt A accretion. • D for Pt B: accrete attempt is based on QWD, and QWD does not pay for Part B. • E: no Medicare entitlement. If recipient appears entitled to Medicare, refer to SSA. For all these worker messages: If data in MMIS has been verified as correct, contact MMIS User Services. TIP: check the Entitlement/Non-Entitlement code on RBUY and RBYB when this worker message is received.

  44. Entitlement/Non-Entitlement Example NEXT: RBYB 06/20/08 11:25:30 MMIS RECIP BUYIN-RBYB FMLMMBP 00000000 00/00/00000 * BIRD BIG A * MEDICARE ID: 000000000A ********************************** ENTITLE/NON-ENTITLE: C PART (B) ACCRETE REQUEST DATE: ACCRETE DATE: PART (B) DELETE REQUEST DATE: DELETE DATE: --------------------------BUYIN MONTHLY TRANSACTIONS--------------------------- TXN TXN SUB ACCRETE DELETE ----- PREMIUM ------ DATE CODE CODE DATE DATE AMOUNT DATE • 10/01/08 2161 E 06/01/08 Pt B Entitlement/Non-Entitlement codes available via PF12: • C NOT ENTITLED NO DISABILITY • D COVERAGE DENIED • F TERMINATED INVALID VOIDED • G ENTITLED GOOD CAUSE • N NOT ENTITLED FOREIGN OR DUAL • R REFUSED BENEFITS • S TERMINATED NO ENTITLE ESRD • T TERMINATED NON PAY PREMIUM • W VOLUNTARYWITHDRAWAL • Y ENTITLED PREMIUM PAYABLE

  45. Buy-In Worker Messages BUY-IN TERMINATED DUE TO DEATH. VERIFY DATE OF DEATH • Txn: 16 A/B • Definition: CMS deleted recipient from buy-in due to death • MMIS: adds delete date on RBUY/RBYB and ends RMCR span • Action: verify recipient’s status. If death is incorrect refer client to SSA to correct and reopen Medicare. If deceased, add DOD and close case.

  46. Buy-In Worker Messages NEW MEDICARE CLAIM NBR REPORTED ON BUY-IN FILE • Txn: 23xx • Definition: Medicare number changed. • MMIS: new claim number added to MMIS, prior number moves to RIDS • Action: update claim number in MAXIS

  47. Buy-In Worker Messages SSA REPORTS NON MN ADDRESS. VRFY/UPDATE CLIENT ADDRESS • Txn: 1728 • Definition: CMS deleted from buy-in because another state has requested accretion or SSI records indicate residence in another state. • MMIS: delete date added to RBUY/RBYB • Action: verify client address. If still a Minnesota resident, refer to SSA. If not, close case.

  48. Buy-In Worker Messages CMS REPORTS SSI BEGIN. MMIS UPDATED. • Txn: 86 • Total txn: 590 (March) • Definition: Medicare beneficiary became SSI eligible (with potential buy-in eligibility). Txn may also include Part A entitlement date • MMIS: SSI start date added to RMSC, and Medicare start date if included. May trigger a categorical accretion if other factors met. • Action: verify SSI amount for effect on other programs

  49. Buy-In Worker Messages CMS REPORTS SSI ENDED. RMSC UPDATED • Txn: 87 • Total txn: 443 (March) • Definition: SSI eligibility ended (can also end buy-in unless meets another basis for buy-in) • MMIS: deletes SSI Start Date if currently populated • ACTION: Verify status of SSI payments for other programs’ use. This may also indicate a temporary ending of SSI payments.

  50. Buy-In Worker Messages SSA REPORTS RECIPIENT NO LONGER ELIGIBLE FOR MEDICARE • Txn: 15 • Definition: deleted from buy-in because Medicare ended • MMIS: delete date added to RBUY/RBYB and Medicare end date added on RMCR • Action: review client record, particularly entitlement coding. If Medicare eligibility appears to exist, refer client to SSA. Re-open Medicare if eligibility is re-established.

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