In response to our blog last week on Medicaid dual status identification, we had a number of people inquire as to the best way to determine correct dual eligible statuses for their Medicare Advantage members.
We note that determining correct dual status is more and more important these days because:
- The new HCC model has a community demographic breakout that now pays differently for full and partial duals, among others. Reconciling the difference is critical to ensure correct reimbursement, especially if you are in an area of the country where moves from partial to full dual eligible status are very common.
- In 2020, all Dual Eligible Special Needs Plans (D-SNPs) are slated to convert to integrated dual eligible plans. Coordination with state Medicaid agencies will go away. For those coordinating now, determining dual status is less important as plans do not process the secondary cost-sharing claims. However, in an integrated framework, the paradigm shifts. Plans will need to pay Medicare cost-sharing for some of the dual categories. In addition, states will wrap in any miscellaneous Medicaid-only benefits for some of those members too. Thus, plans will need to understand what dual eligible category the member fits into because the plan needs to determine if it pays a member’s Medicare cost-sharing and covers any added Medicaid-only benefits.
- CMS now requires plans to reconcile with the Medicaid agency each month to ensure that a member is eligible for enrollment in a D-SNP. D-SNPs must do this on enrollment in the plan and monthly thereafter. Plans not doing so are at risk of compliance actions.
As always, verifying dual eligible status is a complicated subject as numerous data points are sent by the Centers for Medicare and Medicaid Services (CMS) on various files. Here is an overview:
- Information on a Medicare beneficiary’s Medicaid status is reported during the enrollment process on both the Batch Eligibility Query (BEQ) and actual accretion of enrollment (TRRs/TRCs) to CMS. However, these codes tend to have partial information; for example, whether the beneficiary has any Medicaid status (Y/N) and whether he or she is Full or Partially eligible (F/P). This is generally not enough for all a plan needs to know.
- The Monthly Membership Report (MMR) has similar data as above but in field 84 of the MMR there is a comprehensive breakout of a duals actual program qualification (including whether a beneficiary is a QMB Only, QMB Plus (with full Medicaid), SLMB Only, SLMB Plus (with full Medicaid), otherwise another Full Benefit Dual Eligible (FBDE, or full Medicaid), and other partial dual statuses. See our earlier blog here for some explanations about these categories.
- CMS has told plans not to rely on the MMR report above, but the new Medicare Advantage Medicaid Status (MAMS) report, which has the same level of detail but may be more accurate or up to date. MedHOK is working with its client plans to determine what the lag is between the MMR and the new MAMS, which has been around since 2017. The breakout in field eight of MAMS for dual categories is as follows:
- 01 = Eligible - entitled to Medicare - QMB only (Partial Dual)
- 02 = Eligible - entitled to Medicare - QMB AND Medicaid coverage (Full Dual)
- 03 = Eligible - entitled to Medicare - SLMB only (Partial Dual)
- 04 = Eligible - entitled to Medicare - SLMB AND Medicaid coverage (Full Dual)
- 05 = Eligible - entitled to Medicare - QDWI (Partial Dual)
- 06 = Eligible - entitled to Medicare - Qualifying individuals (Partial Dual)
- 08 = Eligible - entitled to Medicare - Other Dual Eligibles (Non QMB, SLMB, QDWI or QI) with Medicaid coverage (Full Dual)
- 09 = Eligible - entitled to Medicare - Other Dual Eligibles but without Medicaid coverage (Non-Dual)
- 10 = Other Full Dual
While plans are told to use the MAMS report information, it is not a substitute for querying actual dual status against a Medicaid Management Information System (MMIS) database. This will have the most accurate information a plan can use each month to track whether a member is eligible for a D-SNP (dependent on the type of D-SNP a plan files for), actual dual codes are accurate for calculation of correct risk adjustment payments, and to determine whether an enrollee in its SNP plans get cost-sharing protection and additional Medicaid-only benefits. Remember, too, that cost-sharing protections apply to QMB Only, QMB Plus, SLMB Plus and FBDE categories in your non-SNP plans. While you don’t pay those secondary or crossover claims, this is an important protection and benefit for these enrollees.