HI DAL00208.070 Proper Coding of the State and County (SCC) of Residence for Medicare Beneficiaries Who Elect Medicare Advantage (MA) Plans

See HI 00208.070

A. Background

A number of Medicare beneficiaries are choosing to have their medical care provided through Medicare Advantage (MA) Plans. To help SSA ensure delivery of world class service to beneficiaries in MA Plans; claims, service, and teleservice representatives must correctly code the State and county code (SCC) on the MBR.

Instructions for title II change of address input, (MSOM T2PE 003-001), require employees to enter the SCC of residence when the beneficiary's residence address is different from his/her mailing address. The Centers for Medicare and Medicaid (CMS) use the SCC to verify that a member of an MA Plans lives in a county in which the MA Plan is certified to operate. When an MA Plan enrolls a beneficiary who appears to reside outside its service area according to the SCC on the MBR, CMS questions the enrollment and requires the MA Plan to resolve the residence address.

B. Procedure

1. MA Plan action

When an MA Plan identifies a case for which the SCC appears to be incorrect on the MBR, it will forward the "Request for Address Corrections, MA Plan Involved—ACTION" memorandum (Exhibit 1) to the servicing FO. An address verification signed by the beneficiary (Exhibit 2) will accompany the request; this will allow the FO to make necessary address changes.

2. FO action

Upon receipt of the request, the FO will review the MBR, paying particular attention to the potential SCC discrepancy. The FO will then take one of three actions:

If the SCC (of residence) and/or address are incorrect on the MBR, the FO employee should correct the appropriate fields(s) on the MBR. The FO is not required to notify the MA Plan of its corrective action. The MA Plan will monitor correction of the SCC through CMS reports and will notify the CMS Regional Office if corrections have not been made by SSA timely (within 30 days of receipt). The CMS Regional Office will follow-up with SSA Regional Office on these cases.

NOTE: If the FO employee changes the address on the MBR, allow 2 days for the address correction to pass to the HIQR.

You may identify some cases in which the mailing address (which was also the residence address) on the MBR is correct but the system apparently derived an incorrect SCC. Please notify the RSI Team of such cases, and we will ask Central Office to make any necessary systems changes.

  • If the MBR and HIQR are correct (i.e., the SCC of residence and address on the MBR and HIQR agree with the beneficiary's statement), no further action is necessary.

  • If the SCC on the HIQR is incorrect, the FO should forward the case to the following address:

    Attn: Managed Care
    1301 Young St., Room 833
    Dallas, Texas 75202-4348

Upon receipt, the CMS Regional Office will review and correct its records.

NOTE: There will be few cases of this type. FO employees should not routinely mail all SCC forms to the CMS RO.

Exhibit 1

To:      SSADO--_________________

ATTN: Health Insurance Coordinator

From:  Medicare Advantage Plan

Name:    __________________________________

Address: __________________________________



Name of MA Plan Contact: __________________________________

Contact Phone Number: __________________________________


CMS uses the State and County code from the MBR to verify that an MA Plan member lives in a county in which an MA Plan is certified to operate; therefore, the State and County code should always match the beneficiary's residence address. When an MA Plan enrolls a beneficiary who resides outside its service area according to the State and County code on the MBR, CMS questions the enrollment and requires the MA Plan to resolve the residence address with the Social Security Office.

Please correct any erroneous information on the MBR with the verified information attached for the Medicare beneficiaries. In many cases, only the State and County code needs to be corrected on the MBR.

Exhibit 2