GIS 16 MA/005: Changes to eMedNY for Certain Medicaid Recipient Coverage Codes

The purpose of this General Information System (GIS) message is to advise local departments of social services (LDSS) of a recent update to eMedNY claims processing and EMEVS messages that occurred on January 21, 2016. This update effects Qualified Medicare Beneficiaries (QMB) who have Coverage Code 06 (Provisional) or 18 (Family Planning Benefit Program-FPBP).

Previously, continuous coverage was provided to Medicaid recipients who turn age 65 and no longer qualify under the MAGI category (i.e., are not a parent or caretaker relative). Coverage for these individuals was continued until the end of their 12-month authorization period, and they were transferred at renewal from NYSOH to the LDSS.

Recipient Coverage Code "09" is defined as "Medicare Savings Program only" (MSP) and is used along with an eMedNY Buy-in span and MSP code of "P" to define a Qualified Medicare Beneficiary (QMB). QMB individuals may also apply for Medicaid and participate in the spenddown program. Such individuals must choose to either use the Medicare premium to meet or reduce the spenddown or have the premium paid under the MSP and retain a higher spenddown obligation. In months where the individual meets the spenddown obligation, staff are instructed to enter the appropriate coverage in WMS for the number of months the spenddown has been met. Upstate WMS is programmed to automatically revert back to Coverage Code 09 following a spenddown period as long as there are remaining months in the authorization period.

NYC WMS is not automated to revert back to 09 coverage in these situations. This can result in an ongoing Buy-in span and a Medicaid authorization period with Provisional coverage (Coverage Code 06). Although this combination of codes does not prevent payment of the Medicare premium, it does prevent payment of other QMB-only services, such as Medicare coinsurance and deductibles. As of January 21, 2016, eMedNY will pay claims for QMB-only services for individuals with Coverage Code 06 and MSP code P. In these situations, NYC staff are reminded to enter 06 coverage for the number of months remaining in the authorization period after the month the spenddown is met.

Some Medicare beneficiaries who are enrolled in the Family Planning Benefit Program (FPBP) are also income eligible for QMB. Coverage Code 18 (FPBP) in combination with a Buy-in span and an MSP code of P will allow payment of QMB-only services, such as Medicare coinsurance and deductibles as of January 21, 2016.

Providers will receive the following eligibility messages when verifying coverage on EMEVS and ePaces:

"Medicare coinsurance and deductible only" for individuals with Coverage Code 06 and an MSP code of P.

"Family Planning Benefit and Medicare Coinsurance and Ded" for individuals with Coverage Code 18 and an MSP code of P.