BASIC (05-11)

NL 00720.002 Special Instructions for MADCAP Health Insurance (HI) and Supplementary Medical Insurance (SMI) Paragraphs

A. Introduction

In most instances, the system will produce complete HI/SMI information based upon:

  • information contained on the Master Beneficiary Record (MBR) and or

  • substantive data contained on the input record.

B. Description of categories for HI/SMI paragraphs

To ensure that the MADCAP beneficiary notice will report on the actions taken in a logical sequence, a priority has been given to each HI/SMI paragraph generated. To determine assignment priority, the paragraphs have been grouped into three categories:

  1. award paragraphs,

  2. payment adjustment paragraphs and

  3. termination paragraphs.

The paragraph priority and a brief description of the paragraph's contents are in the following instructions.

1. Category 1 — Award Paragraphs

HI/SMI UTI

 

Usage

HIB188 .

SMI Refusal

HIB189 .

Railroad Jurisdiction

HIB022 .

Coverage Transferred to Another Claim Number

ENT051 .

HI Date of Entitlement

HIB191 .

HI and SMI Date of Entitlement

ENT052 .

SMI Date of Entitlement

HIB095 .

Change in Date of Entitlement to SMI

HIB254 .

Change in Date of Entitlement to HI and SMI

HIB255 .

Change in Date of Entitlement to HI

HIB193 .

Premium Amounts and Effective Dates

HIB002 .

Temporary Substitution of Notice for Health Insurance Card

HIB052 .

SMI Refusal Procedure

HIB194 .

State Buy-In

HIB015 .

Civil Service Buy-In

HIB195 .

Private Group Buy-In

MHP054 .

Termination of State Buy-In

HIB196 .

Termination of Private Group Buy-In

HIB197 .

Termination of Civil Service Buy-In

2. Category 2 — Payment Adjustment Paragraphs

HI/SMI UTI

 

Usage

HIB039 .

Initial Premium Billing Due to Suspension or Deferred Status that Will Mature Beyond the Current Year

HIB217 .

Initial Premium Billing Due to One-Check-Only Adjustment Plus Suspension

HIB218 .

Final Premium Adjustment Due to Termination of Benefits

HIB219 .

Premium Adjustment Due to Deferred Action that Will Mature in Current Year

HIB220 .

Initial Premium Adjustment Due to SMI Entitlement

HIB221 .

Premium Adjustment Due to Current SMI Entitlement and Prior Period of SMI Entitlement

HIB223 .

Subsequent Premium Adjustment and PINQ Record Adjustment

HIB224 .

Premium Adjustment and PINQ Record Adjustment Due to Resumption of Benefit Payments

3. Category 3 — Termination Paragraphs

HI/SMI UTI

 

Usage

HIB041 .

HI Termination Due to DIB Cessation After 25th Month of Marriage of DAC

HIB234 .

SMI Withdrawal

HIB215 .

HI and SMI Termination Due to DIB Cessation After the 25th Month

HIB235 .

Ineligibility for HI/SMI Due to DIB Cessation Prior to 25th Month

HIB236 .

Premium Adjustment Due to SMI Termination

HIB237 .

Disability Cessation—Premiums Due for a Future Month

HIB244 .

Disability Cessation—DIB Overpayment and Premiums Due for a Future Month

HIB170 .

Beneficiary Under age 65—CRD Entitlement—Benefits Terminated for any Reason other than T1, T2, or T5—HI/SMI Entitlement Continues—SMI Billing Necessary

HIB171 .

Beneficiary Under Age 65—CRD Entitlement—Benefits Terminated For Any Reason Other Than T1, T2, or T5—HI Entitlement Continues—State Buy-In Continues

HIB239 .

Beneficiary Under Age 65—CRD Entitlement—Benefits Terminated For Any Reason Other Than T1, T2 or T5—HI Entitlement Continues

HIB240 .

Change of Address to Foreign Country—Beneficiary Enrolled in HIB Only

HIB241 .

General Description of the Medical Program Outside the United States

HIB242 .

Auxiliary Beneficiary Age 65 or Over—Terminated T3, T8, or T9 New Health Insurance Card—SMI Only

HIB243 .

Auxiliary Beneficiary Age 65 or Over—Terminated T3, T8, or T9 With State Buy-In or Third Party

4. Category 4 – Part C or Part D Paragraphs

HI/SMI

UTI

Function

Caption

Part C or D

Will also Generate

MHP033

Introductory UTI for Medicare Prescription Drug Plan

Information About Medicare Prescription Drug Plan Costs

Part D

If any of the following UTI's are generated, then generate MHP033

MHP036

MHP039

MHP043

MHP009

Introductory UTI for Health Plan Premiums

Information About Health Plan Premiums

Part C

If any of the following UTI's are generated, then generate MHP009

MHP035

MHP038

MHP015

MHP035

Amount of Part C Premiums Withheld From PMA

Information About Health Plan Premiums

Part C

 

MHP038

Amount of Part C Withheld From CMA Payment

Information About Health Premiums

Part C

 

MHP015

Health Plan

Premiums deducted from monthly benefits

Information About Health Plan Premiums

Part C

 

MHP012

Advise That All Premiums Due To Date Have Been Withheld

Information About Health Plan Premiums

Part C

If any of the following UTI's are present, then generate

MHP035

MHP038

MHP015

MHP017

Health Plan Premiums No Longer Being Deducted

Information About Health Plan Premiums

Part C

 

MHP018

Advise Beneficiary To Contact Health Plan Carrier For Questions

Information About Health Plan Premiums

Part C

If any of the following UTI's are present, then generate MHP018

MHP009

MHP035

MHP038

MHP015

MHP012

MHP017

MHP013

Advise Beneficiary That Some Managed Health Plans Offer Premium Reduction

Information About Health Plan Premiums

Part C

 

MHP016

Change In Health Plan Premium Deduction Amount

Information About Health Plan Premiums

Part C

 

MHP036

Medicare Prescription Drug Plan costs deducted from the PMA check

Information About Medicare Prescription Drug Plan Costs

Part D

 

MHP039

Medicare Prescription Drug Plan costs deducted from the CMA check

Information About Medicare Prescription Drug Plan Costs

Part D

 

MHP043

We will continue to deduct Medicare Prescription Drug Plan costs from monthly benefits

Information About Medicare Prescription Drug Plan Costs

Part D

 

HIB238

Introductory UTI for Health Plan Premiums and Medicare Prescription Drug Plan Costs

Information About Health Plan Premiums and Medicare Prescription Drug Plan Costs

Part C and D

If any of the following UTI's are generated, then generate HIB238

MHP037

MHP040

MHP044

MHP037

Health Plan Premiums and Medicare Prescription Drug Plan costs deducted from the PMA

Information About Health Plan Premiums and Medicare Prescription Drug Plan Costs

Part C and D

 

MHP040

Health Plan Premiums and Medicare Prescription Drug Plan costs deducted from the CMA

Information About Health Plan Premiums and Medicare Prescription Drug Plan Costs

Part C and D

 

MHP044

Health Plan Premiums and Medicare Prescription Drug Plan costs deducted from monthly benefits

Information About Health Plan Premiums And Medicare Prescription Drug Plan Costs

Part C and D

 

MHP041

All Medicare Prescription Drug Plan costs due to date have been withheld

Information About Medicare Prescription Drug Plan Costs

Part D

If any of the following UTI's are used, then generate MHP041

MHP036

MHP039

MHP043

MHP042

All Health Plan Premiums and Medicare Prescription Drug Plan costs due to date have been withheld

Information About Your Health Plan Premiums And Medicare Prescription Drug Plan Costs

Part C and D

If any of the following UTI's are used, then generate MHP042

MHP037

MHP040

MHP044

MHP047

Medicare Prescription Drug Plan costs no longer deducted

Information About Medicare Prescription Drug Plan Costs

Part D

 

MHP048

Health Plan Premiums or Medicare Prescription Drug Plan costs no longer deducted

Information About Health Plan Premiums and Medicare Prescription Drug Plan Costs

Part C and D

 

MHP049

Contact Medicare Prescription Drug Plan carrier if they have any questions about their Medicare Prescription Drug Plan costs

Information About Medicare Prescription Drug Plan Costs

Part D

If any of the following UTI's are present, then generate MHP049

MHP033

MHP036

MHP039

MHP043

MHP041

MHP047

MHP050

Contact Health Plan for any questions about Health Plan Premiums and Medicare Prescription Drug Plan costs

Information About Health Plan Premiums and Medicare Prescription Drug Plan Costs

Part C and D

If any of the following UTI's are present, then generate MHP050

HIB238

MHP037

MHP040

MHP044

MHP042

MHP048

MHP045

A change in the amount we deduct for Medicare Prescription Drug Plan costs from monthly benefits

Information About Medicare Prescription Drug Plan Costs

Part D

 

MHP046

A change in the amount we deduct for Health Plan Premiums and Medicare Prescription Drug Plan costs from monthly benefits.

Information About Health Plan Premiums and Medicare Prescription Plan Costs

Part C and D

 

C. Procedure for initial award actions

When a technician processes an initial award and uses a notice completion code of “C” or “I”, the MADCAP system determines what HI/SMI paragraphs will generate based on the HI/SMI data on the MBR.

The system will generate the:

  • appropriate paragraphs showing the entitlement dates to HI and or SMI, premium rate(s) and effective dates,

  • appropriate paragraph for a State buy-in, group payer, etc., if applicable and

  • premium billing paragraphs if benefits are not currently payable.

D. Procedure for entitlement conversion actions

When a technician takes an entitlement conversion action and the beneficiary is already on the MBR and has HI and/or SMI coverage, the generated paragraphs will be similar to the ones sent for initial award cases. The most common types of entitlement conversion actions are a “B” (wife) to “D” (widow) or a disability (DIB) to retirement (RIB) conversion.

1. Automatically generated paragraphs

To have the system automatically generate applicable paragraphs the case must meet following criteria:

  1. the technician must request a complete notice (indicated by a “C” in the first position in the Enclosure Notice Block on the MACADE history screen or an incomplete notice (indicated by an “I” in the first position in the Enclosure Notice Block);

  2. enrollment data must be present on the MBR for any beneficiary in the PIC that the notice is being prepared for;

  3. the prior and current LAF's of the beneficiary involved are not “T”.

2. Manually input paragraphs

There are two completion codes, which can be used when the benefit authorizer wants to input the HI/SMI paragraphs rather than have the system self-generate these paragraphs. These two codes are “B” and “H”.

a. “B” Code

When the “B” code is indicated in the first position in the Enclosure Notice Block, the system will produce an incomplete MADCAP notice and will not self-generate any HI/SMI paragraphs, except those specifically designated as “Systems Generated.” and HIB052 and HIB223 if they apply. For further discussion of HIB052 and HIB223 see NL 00720.002 D.4.) All other “HI/SMI” paragraphs must be coded in the Enclosure Notice Block on the MACADE history screen.

b. “H” Code

When the “H” code is indicated in the first position in the Enclosure Notice Block, the system will produce a complete MADCAP notice, but will not generate any HI/SMI paragraphs except those specifically designated “Systems Generated.” and HIB052 (“Notice of SMIB Refusal Procedure”) and HIB223 (“Subsequent Premium Adjustment and SOBER Record Adjustment”), if they apply. For further information about HIB052 and HIB223 see NL 00720.002 D.4.)

Technicians must code all other “HI/SMI” paragraphs in the Enclosure Notice Block on the MACADE history screen.

3. Miscoding

Codes “B” and “H” are the only two completion codes that allow technicians to input the “HI/SMI” paragraphs and any associated Fill-in Values. If the technician uses any other completion code and designates “HI/SMI” paragraphs, the system generates the designated paragraphs and alert the case for post-adjudicative review.

4. Exceptions to enclosure notice block coding rules

Regardless of what code is in the Enclosure Notice Block, the MADCAP program automatically generates paragraphs HIB052 and HIB223 based on substantive information on the input record and the MBR, whenever applicable.

a. Paragraph HIB052

Paragraph HIB052 explains the claimant's right to refuse SMI and the procedure for doing so. On initial awards only, the technician should code a SMI-START date if the claimant is within 2 months of age 65. This also applies if the 23rd month of disability or later has occurred and if the claimant has made no SMI election. This code results in automatic enrollment in SMI and automatically generate paragraph HIB052 . The mailroom will enclose a Form CMS-2690 (Request for Cancellation of SMI) and an envelope with the award notice.

b. Paragraph HIB223

When the technician processes an adjustment action on a LAF C to C case and there is a premium arrearage or overage, the system will automatically adjust the CMA check. Since the technician is unaware of the premium status and of the adjustment made to the CMA check, the notice information input could not contain any information regarding the premium and adjustment. Therefore, the MADCAP system has been programmed to automatically generate paragraph HIB223 ; “Notice of Subsequent Premium Adjustment and SOBER Record Adjustment” when all of the following criteria are met:

  • an adjustment action is taken on a LAF C to C case;

  • the MBR reflects an open period of SMI; and

  • there is an arrearage or overage.

c. Paragraphs HIB240 and HIB241

Paragraphs HIB240 and HIB241 pertain only to foreign-address beneficiaries. HIB240 applies when there is a change in address to a foreign country and the beneficiary is enrolled in HI (Part A) only. HIB241 is a general description of the Medical Program outside the United States. Because of the difficulty involved in determining whether or not a beneficiary actually resides outside the U.S., these two paragraphs will never be automatically generated.

When HIB240 and or HIB241 are applicable, the technician must request them regardless of whether a “C,” “I,” “B,” or “H” notice completion code is present.

E. Procedure for folder documentation

Only the notice completion code will be present in the block annotated “Additional Payment Information” on Form SSA-3925–C1 (Determination of Benefit Adjustment)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720002
NL 00720.002 - Special Instructions for MADCAP Health Insurance (HI) and Supplementary Medical Insurance (SMI) Paragraphs - 05/20/2011
Batch run: 05/20/2011
Rev:05/20/2011