GIS 10 MA/009: Enhancements to eMedNY as a Result of the Medicare Modernization Act (MMA) File

The purpose of this General Information System message is to inform local districts of changes and enhancements to the eMedNY Third Party subsystem screens effective February 2010. On a monthly basis, the Department creates a file of all dual eligibles and forwards it to the Centers for Medicare and Medicaid Services (CMS). CMS matches the individuals with their files and returns Medicare eligibility data on a response file, which is referred to as the Medicare Modernization Act (MMA) file. The changes referred to in this GIS are based on information the Department receives monthly on the MMA file.

I. Medicare Advantage Plans (Medicare Part C)

Medicare Advantage plans, also referred to as Medicare Part C plans, are treated as commercial policies on eMedNY. Medicare Advantage plans reported on the MMA file will be automatically loaded onto the Third Party Liability (TPL) Policy Page in eMedNY. These policies will be identified with a value of "1" in the Medicare HMO Indicator "MCARE HMO" field. "Hybrid" Medicare plans will also be posted and identified with an indicator value of "2". Hybrid plans are Medicare health plans that combine Medicare Advantage type services along with original Medicare type services. When the MMA file shows a plan termination, the plan will be end dated.

When a Medicare Advantage plan is loaded into eMedNY, the Third Party benefit codes will be populated with standard Medicare Advantage plan benefits, including optional dental and optical benefits:

• 3 Inpatient
• 4 Home Health
• 5 Emerg Room
• 6 Clinic
• 7 Phys Hosp
• 8 Phys Office
• 9 Nursing Home
• 10 Drug Recovery
• 13 DME
• 14 Transp
• 15 Dental
• 16 Optical
• 17 Sub Abus Inp
• 18 Sub Abus Out
• 19 Psch Inpat
• 20 Psch Out
• 21 XRAY
• 22 Hospice

Since dental and optical are optional benefits, district staff may remove these from the scope of benefits list without voiding the entire policy and re-posting it. This is an improvement to previous functionality.

As a result of utilizing the MMA file to identify Medicare Advantage plans and to post them on eMedNY, it is anticipated that providers will be seeing this coverage more frequently on eligibility transactions and may have more billing questions. The Office of Health Insurance Programs has provided billing instructions to providers via the November 2009 and January 2010 issues of the Medicaid Update. All billing questions should be referred to the CSC call center at (800) 343-9000. For general information regarding dicare Advantage Plans, refer to 09 OHIP/INF-1.

Me

II. HMO Indicator/ Medicare Advantage Indicator

The field descriptor, "MCARE HMO" on the TPL Policy Page will be changed to "MCARE ADV". This is a more accurate description, as a Medicare Advantage plan can be other than an HMO plan.

A one time only database update will occur to convert the current Medicare Advantage indicators. Based on the MMA file, all records will be auto-assigned one of three new "MCARE ADV" indicators:

• 0 = NOT MCARE (not an Advantage plan)
• 1 = MCARE ADV (a Medicare Advantage plan)
• 2 = MCARE HYB (a hybrid Medicare plan)

In order to protect the validity of the data, the "MCARE ADV" field will be AD only. Only system updates are allowed in this field.

Local districts are no longer required to data enter Medicare Advantage policies in the Third Party subsystem, as these policies will be loaded automatically via the MMA file.

Commercial policies are traditionally identified with a 2 digit carrier code. Although Medicare Advantage policies are commercial policies, they will be identified by their Medicare Advantage Plan Contract ID. This is a 5 digit code that begins with the letter H or R and is followed by 4 numbers. A Medicare Advantage plan look-up table is viewable under the Third Party/Carrier TAB. Districts can use this to find the name of the plan based on the Contract ID.

Program of All-inclusive Care for the Elderly (PACE) plans should never be entered in the Third Party subsystem. PACE plans are reimbursed via a monthly managed care rate and are identified via the Prepaid Capitation Plan (PCP) Information subsystem.

Also identified in the PCP subsystem are the Medicaid Advantage and Advantage Plus enrollments. Medicaid recipients may voluntarily enroll in a Medicaid Advantage or Medicaid Advantage Plus managed care program, but only if they enroll in the Medicare product of the same plan. When this type of enrollment occurs, the Medicare plan will automatically be posted in the Third Party subsystem as a Medicare Advantage plan. However, the district is still required to enter an enrollment in the PCP subsystem for the Medicaid Advantage or Advantage Plus component of this coverage.

An enrollment entry line for the Medicaid Advantage/Plus program will generate an "excluded" error when its Medicare Advantage plan counterpart is already posted in the Third Party subsystem. In order to successfully enter appropriate enrollments on PCP, districts will need to end date the Medicare Advantage span. These steps should also be followed when recipients move from a Medicaid Advantage product to a Medicaid Advantage Plus product.

Districts should never void or end date any Medicare Part A, B, D or HIC span, as these spans will not interfere with Medicaid Advantage or Medicaid Advantage Plus enrollments. These instructions are for upstate districts only; NYC systems will not have this issue.

Districts should continue to enter other third party commercial policies into eMedNY. The "MCARE ADV" field will default to 0 = NOT MCARE on commercial policies.

District staff may continue to post new Medicare data and update existing Medicare eligibility spans. However, neither the Third Party Contractor or LDSS staff will be allowed to void or delete Medicare A and B coverage information for anyone with a Medicare Advantage plan.

III. C Hyperlink

A new hyperlink "MC" will be displayed on the TPL Resource Search Page for policies having the "MCARE ADV" indicator set to "1" or "2". The link will transfer the user to the TPL Policy Page. The Medicare Advantage plan information displayed on the Policy Page will include policy number, scope of benefits, eligibility dates and Source code.

IV. Prospective Medicare Coverage

CMS provides prospective Medicare eligibility dates via the MMA file. End users will see coverage posted in the future on some Medicare Parts A, B and D policies.

All Medicare eligibility spans will be identified with an "R" in the Source code field on the Policy Page and as a "7" on the Search Page when the input source is CMS.

V. Retiree Drug Subsidy RDS

Some recipients are enrolled in a prescription drug plan through their employer/union retiree health plan and therefore receive the Retiree Drug Subsidy (RDS). This information is transmitted to the Department via the MMA file and is displayed on the TPL Medicare Resource Results Page with a field name RDS Begin Date. (Only the most current contiguous coverage period will be displayed.)

These individuals are exempt from enrolling in Medicare Part D, as explained in GIS 06 MA/003.

VI. Low Income Subsidy (LIS) Co-Pay Level

The Medicare Part D co-payment amount varies depending on an individual's Low Income Subsidy level. For calendar year 2010, Medicare Savings Program (MSP) only individuals have a co-payment $2.50 for generic drugs and $6.30 for brand name drugs. Full benefit dual eligibles pay $1.10 for generic drugs and $3.30 for brand name drugs.

There is never a co-payment for Medicaid recipients residing in a medical facility. A medical facility is defined as a nursing home, psychiatric center, residential treatment center, developmental center, or intermediate care facility. Other group residences such as Assisted Living Programs (ALPs), group homes, and adult homes are subject to co-payments.

The current co-payment level in effect for a client will now be displayed on the Medicare Part D Detail Page. The values that may be found in that field are as follows:

• 1= MSP Only
• 2= Full Dual
• 3= Zero

VII. MMA File Monthly Process

The MMA monthly file has been used to obtain Medicare Part D information since January 2006. As of June 2010, this file exchange will become a weekly process. This will greatly decrease the time between enrollment in Part D and the posting of prescription drug plan coverage on the Third Party subsystem.