PROGRAM OPERATIONS MANUAL SYSTEMPart HI – Health InsuranceChapter 008 – Requirement for Entitlement and TerminationSubchapter 10 – Medicare ProcessesTransmittal No. 18, 01/07/2021
The NY Region designed the NYnet MALP website. The websites main menu contains a user guide and a development guide. Detailed instructions for FOs concerning the MALP process is provided in the development guide.
Summary of Changes
HI 00810.010 How the Medicare Attainments and Leads Process Works
A request was received from the NY Regional Office to add the MALP website link for FOs to access. All FOs must use the website to track and maintain their list of assigned cases including OEO DERO cases. Each month, the NY Region will add new actions to the FO listings.
SSA determines Medicare Part B eligibility for SSI beneficiaries living in auto-accrete states. An automated process exists to identify and process Medicare-only claims for uninsured SSI beneficiaries as they near age 65. We refer to this process as the Medicare Attainments and Leads Process (MALP).
One step in this process is to check the earnings record to determine if a SSI beneficiary may be insured for Title II benefits. If so, we initiate development for the Title II claim.
If the SSI beneficiary is not insured for Title II, but all requirements are present on the SSR for entitlement to Medicare Part B, a Medicare Part B-only claim (BIC M) is automatically processed and updated to the Master Beneficiary Record (MBR).
If the information needed to process the claim is incomplete or inconsistent, development is sent to the Office of Central Operations (OCO)/Office of Earnings and International Operations (OEIO) or to the field office (FO) for further processing. If it is sent to OEIO, it will go to:
the Modernized OEO System (MOS) for automated processing, or
the Division of Earnings Record Operations (DERO) for manual processing.
Once a month, the SSI System selects records for beneficiaries who meet all of the following criteria on the SSR:
age 64 and 9 months or older;
entitled to SSI in pay status C01, M01/M02 (with cash payment), or N01 if they are 1619(b) participants;
not entitled to Title II or Railroad Retirement Benefits (RRB);
not enrolled in Medicare Part B;
residing in an auto-accrete state with Medicaid eligibility determined by SSA; and
a citizen of the United States (U.S.) or an alien lawfully admitted for permanent residency (LAPR) in the U.S. who has resided in the U.S. for at least five years.
Records selected are sent to the Informational/Certified Earnings Records System (ICERS) to determine Title II insured status.
ICERS reviews the earnings record for possible Title II insured status and the SSR information for other claim entitlement factors. ICERS will take the following actions:
If the person is fully insured, ICERS sends an ICER output file to the New York (NY) Region Medicare Attainment and Leads Process (MALP) website for development of a Title II claim;
If there are inconsistencies on the earnings record, ICERS sends the information to the OCO/OEIO. OEIO either resolves the inconsistency and reenters the claim in the automated process (MOS), or manually corrects the inconsistency and faxes the request to the field office (FO). We will send an INTERIM RESPONSE for a DERO condition directly to the FO to alert the office of the reason for referral to DERO. We will send a REJECT RESPONSE directly to the FO for resolution. (Refer to SM 00349.300 and SM 00349.400);
If the person is not fully insured, but factors for Medicare Part B entitlement are met, ICERS sends the information to the Alternate Input Method (AIM) process to update the Medicare-only claim to the MBR. (See SM 00349.001). Factors for Medicare Part B entitlement include proven age, US citizenship, lawfully admitted for permanent residence (LAPR), and five continuous years of residency; and
If the person is not fully insured, and all of the factors required for Medicare Part B entitlement are not present, an ICERS output file is sent to the MALP website for further development of the Medicare claim.
This subsection applies to automated actions where we do not need FO involvement.
SMI State Buy-in awards for qualified uninsured SSI claimants are processed via ICERS and AIM/MACADE. ICERS creates the AIM/MACADE record which then goes to the Manual Adjustment, Credit and Award Process (MADCAP). MADCAP processes the uninsured award and updates the MBR with the following data:
SMI BASIS (equal to A),
SMI FILING ( date equal to the SMI START),
SMI DELAY RSN (equal to S),
SMI PREM (START, PENALTY %),
SMI 3PTY (START, CODE, CATEGORY, PENALTY%), and
Citizenship or Lawful Presence data.
AIM/MACADE records are created with enclosure notice block (ENB) coding, H*HMX*Q03. MADCAP sends a notice when we update the MBR with the uninsured award.
If a record excepts out of this process, the MACADE exception will display “AIM (HIMEX)” beside the SSN. Normal processing rules apply when re-entering the MACADE exception. AIM (HIMEX) transactions also appear on the MACADE hardcopy and the MACADE pending file.
The NY Region designed the NYnet MALP website:
The website’s main menu contains a user guide and a development guide. Detailed instructions for FO’s concerning the MALP process is provided in the development guide. All FO’s must use the website to track and maintain their list of assigned cases including OEO DERO cases. Each month, the NY Region will add new actions to the FO listings.
Establish an application for the person in the Modernized Claim System (MCS). Obtain proof of birth, citizenship, lawful presence, and check the MBR for prior or current entitlement. If the individual refuses to file for Title II, see SI 00510.025.
If the person is eligible for Medicare Part B, establish a Part B-only claim on MCS using the EC process if possible. Complete the HI19 screen following these instructions.
NOTE: These Part B claims do not have a signature requirement and it is not necessary to develop for Qualified Medicare Beneficiary (QMB) entitlement.
Use the following guidelines to develop the claim:
If the beneficiary has lag earnings, and if there are gaps on the earnings record, follow instructions in RS 01404.005. If the person meets insured status, process the claim as indicated in HI 00810.010C.1.
Confirm and document that Title II eligibility does not exist on other earnings records, and that we did not overlook insured status for disability benefits in the past.
Resolve any entitlement issues identified by messages on the ICER output document and resolve any discrepancies between the ICER output document and the SSR. (ICERS will always identify issues that must be resolved; name, DOB, alien status or residency, or both).
Input the proven DOB, citizenship/alien status, or LAPR information to the SSR if this information needs correcting. If the SSR does not reflect five continuous years of continuous residency (that is, five years of continuous periods of C01 or 1619(b) status immediately preceding the effective enrollment month, see GN 00303.800).
Establish a SMI START date on the HI19 screen equal to the month an individual meets all of the requirements for SSI or a federally administered State supplement and for Medicare and process the award.
Process a disallowance/denial if a Part B entitlement factor is not met.
NOTE: SSI beneficiaries are not required to file for "Medicare-only" as a condition of SSI eligibility.
SM 00349.001 ICE - Background/Introduction
HI 00815.009 State Buy-In Coverage Chart
SI 02302.010 1619 Policy Principles
HI 00815.030 SSA DO/BO Procedures to Develop Buy-In Coverage in Initial Claims Cases - The Public Welfare Accretion Procedure
HI DAL00815.030 Establishing State Buy-In For SMI in Initial Claims Through The Public Welfare (PW) Accretion Process
SM 03040.040 State Buy-in on Initial Awards
MSOM ICD 003.003 Health Insurance - Title XIX/ Medicaid
GN 00302.010 Evidence of Established Age in SSA Records