GIS 14 MA/020: TPL BUY-IN Deletion Report TRMP0067

The purpose of this General Information System (GIS) message is to remind local departments of social services (LDSS) of the necessity to review the TRMP0067 TPL Buy-In Deletion Report. Routinely working this report will ensure Medicaid dollars are being spent appropriately.

The New York State Office of the State Comptroller (OSC) performed an audit of the Medicare Savings Program (MSP) and concluded there are Medicare premium payments being made for individuals with no active Medicaid eligibility.

In April of 2009, the State Department of Health (SDOH) promoted a system solution to auto-close Medicare Buy-In spans when certain Upstate CNS closing Reason Codes are entered on WMS. This process was later promoted in New York City in March 2011. However, not all closing Reason Codes are included in the auto-close process. If a Medicaid case is closed with a Reason Code not listed for the auto-close process, the local district is required to manually end date the Buy-In span in eMedNY. A list of current CNS closing codes that will auto-close the Buy-In is included in this GIS.

In order for districts to identify cases where the Buy-In span has erroneously remained open after the Medicaid case has been closed, a MOBIUS report was developed. MOBIUS report TRMP0067 TPL Buy-In Deletion Report is an updated monthly report generated for each district. The report is divided into four (4) time periods: 30 days; 60 days; 90 days; and 180+ days. The time periods, in most cases, refer to the amount of time the individual has remained on the Buy-In after the Medicaid authorization has expired.

The TPL Buy-In Deletion Report lists individuals alphabetically by CIN within the four time periods beginning with the 30 day time period and increasing to the 180+ day category. Districts are reminded that the report should be reviewed on a monthly basis. Any case found on this report should be investigated and closed if no longer eligible for premium payments, following proper procedures.

Recipients must receive proper notice when the Buy-In is closed. Manual notice OHIP-0003, "Notice of Medical Assistance Payment of the Medicare Part A and/or Part B Premium" or OHIP-0002, "Notice of Action on Application/Benefit For Medicaid Payment of Medicare Premiums" or CNS notice U80, "Deny Qualified Individual (QI)" (Upstate), or G59, "Deny Qualified Individual (QI) Over Income" (NYC) should be used as specified in the following scenarios.

1. The Medicaid case was correctly closed using a Reason Code that does not auto-close the Buy-In span. A separate determination of eligibility for MSP was made and the individual was not eligible for MSP, but the Buy-In span in eMedNY was not closed.

Action:

• a. Send the OHIP-0002 notice to discontinue payment of Medicare premiums due to ineligibility. Close the Buy-In span in eMedNY.

2. Recipient was no longer eligible for Medicaid. The Medicaid case was correctly closed, but no separate determination was made for MSP, and the information in the case file is current (within the past 12 months).

Action:

• a. Determine MSP eligibility. If eligible, send the OHIP-0003 notice and check, "Continue payment of your Medicare Part A and/or Part B premium" and authorize eligibility for the appropriate Medicare Savings Program in WMS with Coverage Code 09. Ensure that the MSP code in eMedNY and the MSP code in WMS agree with the MSP budget output screen.
• b. If information in the case file indicates that the individual is not eligible for MSP, close the Buy-In span in eMedNY and send the OHIP-0002 notice to discontinue payment of Medicare premiums due to ineligibility.

3. The Medicaid case was correctly closed and no separate determination was made for MSP, but the information in the case file is not current (older than 12 months).

Action: Send the OHIP-0003 notice and the Medicare Savings Program application. Check "Further Information is Needed" on the notice.

• a. If the individual does not return the MSP application, send the OHIP-0002 notice. Select "Discontinue" and enter "Failure to return the MSP application" as the reason for discontinuance. End date the Buy-In on eMedNY.
• b. If the MSP application is returned, and the individual is determined ineligible for MSP, deny the application using CNS Reason Code U80, "Deny Qualified Individual (QI)" (Upstate), or G59, "Deny Qualified Individual (QI) Over Income" (NYC). End date the Buy-In on eMedNY.
• c. If the individual returns the MSP application and is found eligible for MSP, send the OHIP-0002 notice to "Continue" premium payment, authorize the case in WMS with Coverage Code 09. Ensure that the MSP code in eMedNY and the MSP code in WMS agree with the MSP budget output screen.

4. (Upstate only) Agency failed to recertify case. (Example: If case was not properly identified as a QI-1 case in WMS with an MSP code of "U", the automated renewal would not have been generated.)

Action: Send the OHIP-0003 notice and the Medicare Savings Program application. Check "Further Information Needed" on the notice.

• a. If the individual does not return the MSP application, send the OHIP-0002 notice. Select "Discontinue" and enter "Failure to return the MSP application" as the reason for discontinuance. End date the Buy-In on eMedNY.
• b. If the individual returns the MSP application and is found ineligible for MSP, deny the application using CNS Reason Code U80, "Deny Qualified Individual (QI)". End date the Buy-In on eMedNY.
• c. If the individual returns the application and is determined eligible for MSP, send the OHIP-0002 notice to continue premium payment and reauthorize the case in WMS with Coverage Code 09. Ensure that the MSP code in eMedNY and the MSP code in WMS agree with the MSP budget output screen.

Discontinuing Payment of Medicare Premiums

A. To discontinue payment of Medicare premiums, the following entries should be made in the Medicare/Buy-In Resource screen in eMedNY:

1. Select the Coverage Type "BB" from the dropdown box

2. Enter the Buy-In End Date. A 10 day notice must be given and the Buy-In end date must be the last day of the month.

3. Enter the MSP Code currently on record

4. Enter County Trans Code-51 for closed or expired cases or Code 53 for deceased individuals. (Use of Code 53 requires a date of death on WMS)

5. Click the ADD button

6. Click the SAVE button

B. To change an MSP code in eMedNY using a Change transaction code "99" in the Medicare/Buy-In Resource screen in eMedNY:

1. Select the coverage type "BB" from the dropdown box

2. Enter the first day of the current month

3. Select the MSP code

4. Select Change transaction code "99"

5. Click the Add button

6. Click the Save button

Contact the NYSDOH Third Party Liability Unit at 518-473-5330 for questions or assistance in using the Buy-In Deletion Report.

The following reason codes will trigger the auto-close Medicare Buy-In span process. This will significantly decrease the number of cases that require separate action by the worker to close the Buy-In. Prior to using one of the reason codes, the worker must ensure that on-going eligibility for MSP has been determined if applicable. If MSP eligibility is re-established after using one of the reason codes, a new Buy-In span must be entered into eMedNY.

Note: A list of Buy-In closing Reason Codes is also available on eMedNY under the tab labeled "Administration". This list is periodically updated. To view this list, under the "Administration" tab, select "Systems List". Under Subsystem, select "Third Party Liability", and click "Find". Then under the "List Number" select 0001 "TPL WMS Reason Code to Close Buy-In". On the System list search page, click the arrow outlined in red under "Effective Date" to put the list in update mode. A list of reason codes will appear.

NYC Buy-In Closing Reason Codes

A03- MA- Suspended Coverage at Incarceration of Inmate of NYS or Local Facility HH=1

A41- MA/FHP Suspend MA Coverage for 21-64 Year Old Admitted to a Psychiatric Center, HH=1 (NYC)

C35- Disc FHP-PAP, ESHI Not Cost Effective, Ineligible for FHP Due to Equivalent Health Insurance

C90- Disc MA Payment of Health Insurance Premiums for a 21-64 Year Old Individual Admitted to a Psychiatric Center (Upstate)

D74- Woman at 60 Days Post-Partum to Family Planning Benefit Extension Program (24 months ext.), Ineligible for Medicaid/FHPlus/FPBP Due to Income Exceeding 200% FPL, FP

E05- Excess Income Due to COLA Increase

E07- Excess Income Due to COLA Increase and Ineligible Surplus

E12- Didn't Return Form

E15- Pregnant Woman Didn't Return Form

E30- MA Excess Income

E31- Excess Income- MA to TMA Eligible Increased Earnings/New Employment

E32- MA Excess Income Child/Spousal Support Extension

E33- MA Excess Income MA to TMA Guarantee-Increased Earnings/New Employment

E35- MA Excess Income, Single/Childless Couples

E36- MA Excess Income- Child/Spousal Support

E39- MA Excess Income Due to COLA Increase

E58- Failure to Return PCAP Recertification Renewal Notification

E60- Unable to Locate

E62- Between 21-65, in a Psychiatric Institution

E63- Not a State Resident. Close Case when household no longer resides in NYS

E66- Not a State Resident. PA discontinued. No separate MA determination

E72- Institutionalized Public Assistance has been discontinues because the client was admitted or committed to an institution

E79- MA Not Provided in Current Living Arrangement

E90- Client Requested Removal from Case

E95- Death

EF1- Admitted/Committed to Prison Prior to 4/01/08

EF2- MA/FHP Disc Medicare Savings Program of Inmate of NYS or Local Correctional Facility

EF3- Disc MA Payment of Health Insurance Premiums

EF4- Suspend MA Coverage 21-64 Year Old Admitted to a Psychiatric Center or Local Correctional Facility

EF5- Disc MSP for an Individual Admitted to a Psychiatric Center (NYC)

EF6- Disc Medicaid Payment of Health Insurance Premiums for an Individual admitted to a Psychiatric Center (NYC)

F09- MBI-WPD Ineligible Excess Income above 250% of FPL

F10- Failed to Keep Appointment for Initial Eligibility Interview (PA cases only)

F12- Failure to Apply for SSI

F17- Failure to Validate Incorrect SSN

F20- Failure to Provide SSN

F26- Deny MBI-WPD, Excess Resources

F28- Deny MBI-WPD, Excess Income and Excess Resources

F63- In Prison

F64- In Prison Outside of NYS

F92- Non-Qualified PRUCOL Alien Ineligible for Full MA

F93- Failure to Report to Child Support Enforcement Unit (IV-D Requirement)

F99- Incarcerated Individual Released to Custody of U.S. Immig & Customs

Enforcement

G14- Failed to Return Recertification Renewal Notification Form

G39- Died

G48- Deny FHP-PAP, ESHI Not Cost Effective, Ineligible for FHP Due to Equivalent Health Insurance

G58- Annual Fund Exhausted

G59- Discontinue Qualified Individual (QI-1) Over Income

G60- Unable to Locate - BEV Only

G66- Failed to Return Renewal (Recertification) Form OI-1/SLIMB

G77- Not a Resident of District

G88- Deny Medicaid/Family Health Plus/FHP-PAP/FPBP, Client Request (written)

G93- Client's Request- Verbal

G95- Died - BEV Only

G98- Client's Request-Verbal (Timely)

H10- Failure to Provide Resource Information- No undue Hardship

H11- Failure to Provide Resource Information-Undue Hardship

H14- Failure to Provide Proof of US Citizenship/Identity SAA/BVI Match

H25- Discontinue Medicaid, Excess Resources (DAB)

H33- Discontinue Medicaid, Excess Income, Applicant Age 65 and Older, Certified Blind or Certified Disabled

M24- Failed to Submit Computer Match Information

M25- Failed to Respond to Computer Match Call in Letter

M89- Medicare Savings Program Failed to Return Required Documentation QI1/SLIMB

M98- Concurrent Benefits- Intrastate (Within State)

N66- Concurrent Benefits Inter-State

N67- Concurrent Benefits Inter-State (System Generated)

U12- MBI-WPD to MA Excess Income, SD Not Met

U13- Deny Medicaid/Family Health Plus/FHP-PAP/FPBP, Information Non Applying Legally Responsible Relative, Applicant Under 21

U20- Deny MA Fail to Verify did not State Unable to get Summary

U21- Verification Factors Which Affect Eligibility, Unable to get info, Reason Not Good

U23- Deny Medicaid/Family Health Plus/FHP-PAP/FPBP, Information Non Applying Legally Responsible Relative, Applicant Under 21

U57- Discontinue Medicaid Due to Excess Income, FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee, FPBP Ineligible Due to Excess Income or Eligible but Declines, SCC

V13- Deny Medicaid/Family Health Plus/FHP-PAP/FPBP, Failure to Utilize Benefits

V97- Failure to Report Child Support Enforcement Unit (IV-D Requirement)

X13- Deny MA Exc Res Spousal Impov Institutionalized Spouse

X14- No Longer Eligible for MA Payment of AHIP Premiums

X25- Disc MA Payment of Health Insurance Premiums

X50- Disc MA Payment Cobra Continue Group Health Ins. Premiums

X51- Cobra Continue Coverage of Group Health Insurance Premium, Prior Conditional Acceptance

X52- Medicare Buy - In Program QMB

567- Discontinue Qualified Individual (QI), Over Income Due to COLA Increase (System Generated)

816- MA Suspended Coverage at Incarceration of Inmate of NYS or Local Facility HH=1

866- Failed to Return Renewal (Recertification) Form for QI-1/SLIMB (System Generated)

867- Failed to Return Required Documentation QI-1/SLIMB

902- FHP Individuals Who Exceed the FHP Limit due to Cola Increase

905- MA/FHP Exceed FHP Limit are Ineligible for Surplus

939- In Prison (System Generated)

957- No Longer Eligible for SSI

958- MA Rosenburg C

959- MA Rosenburg C Managed Care

962- Excess Income Due to Increase in Social Security Benefit

983- Did Not Return Forms for Recertification (System Generated)

985- Failure to Comply with Recert Procedure- Didn't Return Information (System Generated)

991- Discontinue SSI - Separate MA Determination

994- Did Not Return Forms (System Generated)

995- Did Not Return Information (System Generated)

997- Pregnant Woman Did Not Return Forms (System Generated)

Upstate Buy-In Closing Reason Codes

C51- Suspend MA Coverage 21-64 Year Old Admitted to a Psychiatric Center, HH>1

C53- Disc MA/FHP, Incarceration Out-of-State or Federal

C54- Suspend MA Coverage 21-64 Year Old Admitted to a Psychiatric Center, HH=1

C55- Suspend MA - Coverage for Inmate of NYS/Local Facility w/AC (Upstate)

C57-(Opening)Suspend MA Coverage for Inmate of NYS/Local Correctional Facility w/AC (Upstate)

C58- Disc MA Payment of Health Insurance Premiums of Inmate of NYS or Local Correctional Facility Penitentiary Located Within NYS

C59- Disc Medicare Savings Program of Inmate of NYS

C88- Discontinue MA/FHP/FHP-PAP/Family Planning Benefit Program, Failure to Provide Proof of U.S. Citizenship & Identity

D61- Medicaid to Family Planning Extension Program, Non- Immigrant/ Undocumented Immigrant 60 days Post-Partum

D64- Woman at 60 Days Post -Partum to Family Planning Extension Program Due to Failure to Provide Documentation

D70- Woman at 60 days Post - Partum to Family Planning Benefit Program ( 24 month ext), Ineligible for Medicaid/FHPlus, SCC

D72- Woman at 60 Days Post- Partum to Family Planning Benefit Extension Program ( 24 months ext.), Ineligible for Medicaid/FHPlus/FPBP Due to Income Exceeding 200% FPL, SCC

D73- Woman at 60 Days Post- Partum to Family Planning Benefit Extension Program ( 24 months ext.), Ineligible for Medicaid/FHPlus/FPBP Due to Income Exceeding 200% FPL, FNP

D76-Woman at 60 days Post-Partum to Family Planning Benefit Program ( 24 month ext.) Ineligible for Medicaid/FHPlus, FP

E15- Loss Eligibility Due to Turning Age 22 in Psychiatric Center or Residential Treatment Center, (OMH Only)

E60- Unable to Locate

E62- Deny MA/FHP, Between 21-65, In a Psychiatric Institution

E63- Not a State Resident

E79- MA Not Provided in Current Living Arrangement

E80- Disc Fail to Provide Info about Non- Applying LRR in HH

E95- Disc MA/FHP Deceased

F10- Discontinue MA/RMA/FHP/FHP-PAP, Failed to Return Renewal Form

F12- Failure to Apply for SSI

H10- Failure to Provide Resource Information- No undue Hardship

H11- Failure to Provide Resource Information-Undue Hardship

H30- Disc TMA No Dependent Child Under 21

H31- Disc TMA Fraud (Statewide)

S07- Medicaid Level to Excess Income Due to COLA Increase

S63- Discontinue/Failure to Provide Information to Clear up Discrepancy

U03- Disc MBI-WBD, No Longer Meets Medically Improved Group Requirements, S/CC

U06- Disc MBI-WPD MI Group, Not Working 40 hours or Not Working at Federal Minimum Wage, FP

U07- Disc MBI-WPD, MI Group Not working 40 Hours or Not working at Federal Minimum Wage, FNP

U08- Disc MBI-WPD, No Longer Meets Medically Improved Group Requirements, FNP

U09- Disc MBI-WPD, No Longer Meets Medically Improved Group Requirements, FP

U11- MBI-WPD to MA Exc Inc SD Not Met Turning 65

U13- Deny Medicaid/Family Health Plus/FHP-PAP/FPBP, Information Non Applying Legally Responsible Relative, Applicant Under 21

U16- Disc MBI-WPD MI Group Not Working 40 Hours or Not Working Federal Minimum Wage, SCC

U18- Disc-MBI-WPD Exc Inc and/or Res, FHP Ineligible

U20- Deny MA Fail to Verify did not State Unable to get Summary

U21- Verification Factors Which Affect Eligibility, Unable to get info, Reason Not Good

U27- Disc MBI-WPD Turning 65 Exc Inc and/or Res for MA

U28- Disc MBI-WPD No Longer Working, Exc Inc

U30- MBI-WPD to MA, Exc Inc Non-financial Reasons, SD Not Met

U32- Deny MA Exc Inc. Age 65 & Older

U33- Turning 19, Discontinue Medicaid Due to Excess Income and/or Resources, FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee, FPBP Ineligible Due to Excess Income or Eligible Declines

U40- Disc MA Due to Excess Resources, Age 65 & Older

U57- Discontinue Medicaid Due to Excess Income, FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee, FPBP Ineligible Due to Excess Income or Eligible but Declines, SCC

U58- Discontinue Medicaid Due to Excess Income and/or Resources, FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee, FPBP Ineligible Due to Excess Income or Eligible but Declines FP

U59- Disc MA Due to Excess Income and Resources, Age 65 and Older

U72- Disc MA, Excess Income, COLA, SCC

U77- Concurrent Benefits, Intra-state No Aid Continuing

U78- Concurrent Benefits, Inter-State, Aid Continuing

V13- Deny Medicaid/Family Health Plus/FHP-PAP/FPBP, Failure to Utilize Benefits

V17- Incorrect or Fraudulent Social Security Number

V30- Disc MA/FHP Failure to Comply with IV-D Requirements

V31- Failure to Provide Social Security Number

V38- Disc MA to Fail To Contact Agency

V76- Over 19, Medicaid to FPBP Due to Excess Income, FHP Ineligible Due to Equivalent Health Insurance or Federal Employee

V93- Medicaid to FPBP Due to Excess Income, FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee, FNP Parent

V95- Medicaid to FPBP Due to Excess Income and/or Resources, FHP Ineligible Due to Excess Income, Equivalent Health Insurance or Federal Employee ( FP or MA-SSI Related)

X13- Deny MA Exc Res Spousal Impov Institutionalized Spouse

X18- Discontinue Medicare Buy-In Program QI-1

X23- Disc MA Fail to Provide Amount of Income and/or Resources at Renewal

X28- End of RMA, Disc MA Excess Income, SCC

X48- Discontinue Medicaid Due to Excess Income, FHP Ineligible Due to Excess Income, Equivalent Insurance or Federal Employee, FPBP Ineligible Due to Excess Income or Eligible but Declines, FNP Parent

X51- Cobra Continue Coverage of Group Health Insurance Premium, Prior Conditional Acceptance

X52- Disc Medicare Buy-In Program QMB Only

X53- Medicare Buy In Program (SLMBs)

X70- Disc Qualified Individual (QI-1) Over Income

X80- Medicaid to Spend down Due to Excess Income, FHP Ineligible Due to Excess Income, Chose Spend down, Over 65, Equivalent Insurance or Federal Employee

712- Discontinue Qualified Individual (QI), Over Income Due to COLA Increase (System Generated)

922- Disc MA, Incarceration Out-of-State (SSI Recipient)

941- Not a State Resident (SSI Recipient)

942- Death (SSI Recipient)