HI 00815.063 Systems Processing of State Responsibility Items
The following paragraphs provide an overview of CMS processing of accretion and deletion actions submitted by the States.
A. State Initiated Accretions
Accrete States are responsible for accreting those groups of individuals specified in the buy-in agreement with the exception of SSI recipients. CMS is responsible for accreting SSI recipients. Alert States have accretion responsibility for all coverage groups specified in the buy-in agreement. To assist alert States in identifying SSI recipients who are eligible for Medicare, CMS provides informational SSI accretion alert records to the State on a monthly basis.
B. Matching Accretion Records to the Health Insurance Master Record
CMS maintains the Health Insurance Master (HIM) Record file which contains the current status of all individuals entitled to Medicare as well as records for individuals for whom Medicare is being developed or for whom Medicare has been denied.
When a State submits a buy-in accretion record, it is imperative that the individual be identified by the Health Insurance system to verify that the accretion is being made under the correct Medicare claim number. This identity verification insures that any Part B Medicare established and/or Part B premiums refunded to the beneficiary as a result of the assumption of premium liability by the State are valid. Therefore, before any individual can be accreted to the Third Party Master (TPM) by a State, the accretion record must match a corresponding HIM record.
Listed below are the data fields utilized in the HI matching routine and the portion of each field which is compared to the HIM. An accretion record submitted by the State should always contain at least this identifying information:
Medicare Claims Number — Nine-position social security claim number (or pseudo social security claim number if beneficiary is entitled under a Railroad Retirement Board number) followed by a one or two-position alpha-numeric Beneficiary Identification Code (BIC).
Surname — First six positions.
First Name — First three positions.
Sex Code — One position.
Date of Birth — All six positions. Although only month and year are used for matching, it is important that the day be included so that the correct Medicare entitlement date can be computed.
C. States-Initiated Deletions
States have deletion responsibility for all records which appear on the State"s buy-in account as State responsibility items. However, there are situations under which CMS will delete records for the State (See HI 00815.063.G). States are required to submit deletion actions within a specified timeframe when Medicaid eligibility has been terminated by the State (See HI 00815.063.D).
In alert States where buy-in accretion and deletion responsibility rests with the States, CMS provides informational SSI Accretion/Deletion alert records to assist the State in making timely buy-in determinations. For potential buy-in deletions, CMS generates a deletion alert record, on a monthly basis to alert States. This record is generated only when the buy-in system is notified that SSI has been terminated and the individual currently appears on the buy-in.
In accrete States, all SSI/Buy-in records are under CMS jurisdication and they cannot be deleted by a State-initiated deletion action. However, accrete States are responsible for all other records regardless of whether the item was originally accreted by the State or the item became State responsibility as a result of a transfer of jurisdiction from CMS to the State.
D. Commissioner"s Decision — Limitation on Retroactivity of Deletions
When the buy-in program was implemented in July 1966, States were allowed to delete individuals on a retroactive basis and could annul a person"s entire buy-in coverage period if the State determined that the individual should not have been enrolled in the buy-in program. When the State deleted the individual, the State received the entire amount of premiums paid as a credit to the State"s account. As a result, the individual was held responsible for the entire premium amount. In effect, a hardship condition was placed on the individual when SSA withheld monies from the individual"s Social Security benefit check to recover the premiums which in many instances were substantial.
In 1972, the Social Security Administration published a regulation to prevent this hardship on the individual. The regulation commonly referred to as the “Commissioner"s Decision” limits the retroactivity of the deletion date to 2 months from the month in which the buy-in system receives the deletion request. For example, the State submits a deletion action to CMS in August l985. The deletion date cannot be earlier than June 1985. If the State had entered a date earlier than June 1985 (e.g., April 1985) the buy-in system would automatically adjust the deletion date to conform to the 2 month retroactive deletion rule and the deletion date would be processed with an effective date of June 1985.
E. CMS Response to State Initiated Accretions and Deletions
The CMS Third Party System will provide a response record for each State-initiated accretion or deletion record. The CMS response records for State accretions and deletions will be one of the following types:
An acknowledgement response that the Third Party System has accepted the accretion or deletion action.
A reject response with a definitive code describing the reason for the rejected accretion or deletion action.
An interim response record for the accretion or deletion action that requires additional electronic or clerical investigation to facilitate the completion of the requested action. Generally, an electronic response will be made in the next monthly operation indicating the final disposition of the original request. An electronic response record is not generated in a few situations. Therefore, it is possible for the State to receive a paper document explaining why the original request could not be accomplished.
F. Adjustment of State Accretion Effective Date
All State-submitted accretion actions are screened to the Health Insurance Master record for the presence of Medicare entitlement. In those cases where entitlement exists, the individual"s Medicare entitlement date and the State buy-in effective date are compared. If the State buy-in effective date precedes the individual"s Medicare entitlement date, the Third Party System will automatically adjust the State buy-in date to agree with the individual"s Medicare entitlement date.
G. CMS Initiated Deletions of State Responsibility Items
DEATH DELETIONS — The Social Security Administration receives reports of death from a number of sources in the daily operation of its various programs. If a report of death is received for an individual who is on buy-in, SSA sends a death deletion record to the CMS Third Party System in the regular monthly data exchange. The Third Party System deletes the individual from buy-in effective with the month of death. CMS sends a death deletion notification to the State on the billing file.
INDIVIDUAL"S LOSS OF MEDICARE ELIGIBILITY — SSA, in the course of reviewing its files of Medicare eligibles, may determine that an individual does not currently meet all the requirements for Medicare. Among the reasons are determination that the individual has not attained age 65, that entitlement to disability benefits has ceased, or that requirements for citizenship or alien residency have not been met. SSA sends a deletion record to the Third Party System in the regular monthly data exchange. The Third Party System will delete the individual from buy-in effective with the month and year of Medicare termination.
DELETION AS THE RESULT OF ANOTHER STATE"S ACCRETION ACTION — If an individual is on the buy-in rolls and another State submits an accretion action for the same individual, the original State will receive a deletion. It is assumed that the State which submits the latest accretion action is the State which has jurisdiction. The effective deletion date will be the month prior to the month that the new State assumed jurisdiction.
DELETIONS FROM OTHER SOURCES — CMS may be notified outside of the monthly data exchange that a deletion action is required. Normally, notifications of this nature are submitted on the HCFA-1957, “SSO Report of State Buy-In Problem,” by the Social Security district office or on a memorandum by the State. If a deletion is processed, the State will be notified of the deletion in the monthly data exchange. Even though CMS personnel complete the documents to delete the item, it is not technically a CMS-initiated deletion because CMS is responding to an outside request. Deletion actions taken by CMS for these situations will be identified in the State billing file with a unique transaction code.