Identification Number:
HI 00815 TN 19
Intended Audience:See Transmittal Sheet
Originating Office:Centers for Medicare & Medicaid Services (CMS)
Title:State Enrollment of Eligible Individuals
Type:POMS Transmittals
Program:Medicare,Medicaid
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part HI – Health Insurance
Chapter 008 – Requirement for Entitlement and Termination
Subchapter 15 – State Enrollment of Eligible Individuals
Transmittal No. 19, 12/18/2018

Audience

FO/TSC: CS, CS TII, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;
PSC: BA, CA, CS, DS, ICDS, IES, ILPDS, IPDS, ISRA, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, CR, EIE, ERE, FCR, PETL, RECONR;
OCO-ODO: BET, BTE, CCE, CR, CST, CTE, CTE TE, DEC, DSE, LCC, PAS, PETE, PETL, RCOVTA, RECOVR;

Originating Component

CMS

Effective Date

Upon Receipt

Background

The Centers for Medicare & Medicaid Services (CMS) is requesting approval for the POMS section HI 00815.036, State Response to Public Welfare (PW) Accretion, from subchapter HI 00815, State Enrollment of Eligible Individuals. We have updated this POMS section in compliance with CMS enumerating all Medicare beneficiaries with a new Medicare Number, or Medicare Beneficiary Identifier (MBI). While SSA and CMS can continue to do business with the use of Social Security Number (SSN) and Health Insurance Claim Number (HICN) terminology, when SSA interacts with a beneficiary to provide Medicare Services, SSA will need to access and use the term MBI.

Summary of Changes

HI 00815.036 State Response to PW Accretion

We have made the following changes and updates to this section:

• claim number to beneficiary Medicare Number;

• claim number to Medicare Number;

• spelled out acronyms Public Welfare (PW), Social Security Administration (SSA), Third Party System (TPS), CMS regional office (RO), central office (CO) and field office (FO); and

• incorporated the changes of the Third Party System redesign of 2003. :

HI 00815.036 State Response to Public Welfare (PW) Accretion

A. States' responsibilities for verifying all PW accretions

  • States are responsible for verifying all PW accretions by matching the data they receive from the Social Security Administration (SSA) via the State Data Exchange (SDX) file against their data in the State Medicaid Eligibility File.

  • If the State determines that a PW accretion is erroneous, the State may protest the action.

  • A State has two months following the month in which it received notification of the PW accretion on its billing file to annul the accretion or establish a closed period of State Buy-in coverage, in accordance with Chapter 4, Section 480 of the State Buy-in Manual.

  • If the State does not react timely, the State becomes responsible for the premium liability until it submits a deletion action to the Third Party System (TPS). In this situation, the Commissioner’s Decision is applicable and limits the retroactivity of deletions to processing month minus two. The State is liable for all premiums from the month of accretion to the month of deletion, see HI 00815.063.D Systems Processing of State Responsibility Items.

B. State directs protest to the Centers for Medicare & Medicaid Services (CMS)

The State Agency must direct its protest to the CMS Regional Office (RO) and CMS Central Office (CO).

EXCEPTION: If the beneficiary for whom the State received the PW accretion resides in an auto-accrete State and is in current pay status on the SDX, but the Medicare Number is missing from the unearned income field, the State must ask the SSA Field Office (FO) to use the following force finder procedures: SM 02001.040 MBR/SSR Interface Edits, Alerts and Diaries; and SM 01301.325 Query.

The State should follow up with the FO if the Medicare Number is not established within 90 days.

NOTE: The CMS RO, in the course of the PW investigation, may also ask the FO to establish the Medicare Number in the unearned income field via the force finder procedure.


HI 00815 TN 19 - State Enrollment of Eligible Individuals - 12/18/2018