This technical instruction defines, specifies, and differentiates T-MSIS data elements related to select beneficiary cost sharing information (i.e., copayment, coinsurance, and deductible data). States have varied interpretations of related T-MSIS beneficiary data elements. Consistent reporting allows for accurate interpretation of the data and decreases the administrative burden placed on states and CMS to validate the data.
This technical instruction applies to Medicaid and CHIP fee-for-service (FFS) claims and managed care encounters.
Background Discussion
Importance
Accurate payment information, including beneficiary liability and payment amounts, is critical to support Medicaid and CHIP program integrity, oversight, and administration. This information is used to ensure that Medicaid and CHIP payments to the provider[1] do not exceed the Medicaid or CHIP allowed amount[2] and to evaluate the impact of beneficiary cost sharing liabilities and payments. Accurate reporting of a beneficiary’s financial liability and their actual out of pocket payments is important to safeguard Medicaid beneficiaries and is necessary to evaluate the impact of cost sharing policies on Medicaid expenditures, provider reimbursement, and beneficiary medical service utilization and outcomes.
Beneficiary Cost Sharing
Beneficiary cost sharing is the portion of the Medicaid or CHIP allowed amount the beneficiary pays to the provider for covered services, usually in the form of a copayment, coinsurance, or deductible. An important yet often overlooked aspect of beneficiary cost sharing is the difference between the amount the beneficiary is liable for and the amount the beneficiary pays. In general, a beneficiary (or their representative) is required to pay their entire cost sharing liability amount. The exceptions to the requirement – i.e., that the beneficiary pay their cost sharing liability in full -- are when a provider decides, on a beneficiary-by-beneficiary basis, to waive all or part of the beneficiary’s obligation to pay their cost sharing liability.
Individual income spend-down is not defined as a type of beneficiary cost sharing. Income spend-down is related to the amount an individual must reduce their income by paying for qualified expenses to become eligible for Medicaid coverage[3]. On the other hand, beneficiary cost sharing “means any copayment, coinsurance, deductible, or other similar charge”[4] related to the beneficiary’s portion of a claim’s Medicaid or CHIP allowed amount that the beneficiary must pay for the covered services.
Regulatory Framework
The Social Security Act section 1902(a)(14) allows states to impose copayments, coinsurance, deductibles, and other similar charges for which beneficiaries are liable for on many Medicaid-covered benefits. While a provider can waive[5] a beneficiary’s cost sharing liability, they can only do so on a case-by-case basis. In accordance with the Anti-Kickback Statute[6] and False Claims Act[7] providers are prohibited from routine copayment waivers that are designed to induce additional business.
In accordance with the Social Security Act Section 1903(r)(1)(F)[8], states are required to submit beneficiary cost sharing data through T-MSIS to ensure necessary program integrity, program oversight, and administration. Further, states must provide upstream instructions to ensure providers, programs, and other claim submitting entities accurately report the information.
Challenges
Consistency, reliability, and availability of T-MSIS beneficiary cost sharing data elements varies across states. The causes of these issues stem from several challenges:
- Varying interpretations. States encounter difficulties with consistent interpretation and differentiation among key data elements. For example, states have struggled with determining when to report beneficiary copayment payment amounts in the Total Copayment Amount data element (deprecated as of T-MSIS Data Dictionary V3.0.0) versus the Beneficiary Copayment Amount data element (renamed BENEFICIARY-COPAYMENT-PAID-AMOUNT as of T-MSIS Data Dictionary V3.0.0). States also have had varying interpretations of the Copayment Waived Indicator data element, for which some states are reporting administrative level waivers (e.g., a Medicaid program that waives the copayment) rather than provider level waivers.
- Missing information. Some claims do not contain the information required for T-MSIS reporting. For example, not all claims determine and/or report copayment amounts at the service line, but T-MSIS requires line and header level copayment amounts. Additionally, while T-MSIS collects copayment and coinsurance payment amounts separately, only the combined cost sharing payment amounts are available for some claims —i.e., the claim only contains the sum of the beneficiary copayment, coinsurance, and deductible payment amounts.
- Differentiating liability from payment amounts. For T-MSIS reporting, some states do not differentiate between the cost sharing liability amounts from the paid amounts and report the beneficiary liability amount in data elements defined as beneficiary payment amounts.
CMS Technical Instructions
These T-MSIS technical instructions are designed to address the challenges states face when reporting beneficiary cost sharing liable amounts, payment amounts, and instances of provider copayment waivers.
Consolidated Total Beneficiary Copayment Data Element
Beginning with T-MSIS Data Dictionary V3.0.0, T-MSIS will collect one header-level beneficiary copayment paid amount: TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT (CIP208, CLT155, COT132, CRX089) across all claim file types. T-MSIS will no longer collect the TOT-COPAY-AMT data element (CIP115, CLT066, COT051, CRX042—deprecated as of T-MSIS Data Dictionary V3.0.0).
Data Elements that Report Beneficiary Cost Sharing Liable Amounts
A beneficiary's cost sharing liability amount is the amount the beneficiary is obligated to pay for covered services on a claim. The beneficiary’s cost sharing liability is determined by the State Medicaid or CHIP agency or the managed care organization (MCO) negotiated contract and is the amount the beneficiary is obligated to pay to the provider (i.e., the amount they are liable to pay) toward the allowed amount in the form of a copayment, coinsurance, and/or deductible for covered services on a claim.
There are three data elements that report beneficiary cost sharing liability amounts (all new as of T-MSIS Data Dictionary V3.0.0): TOT-BENEFICIARY-COPAYMENT-LIABLE-AMOUNT (CIP192, CLT239, COT230, CRX163), TOT-BENEFICIARY-COINSURANCE-LIABLE-AMOUNT (CIP293, CLT240, COT231, CRX164), and TOT-BENEFICIARY-DEDUCTIBLE-LIABLE-AMOUNT (CIP294, CLT241, COT232, CRX165).
- States should report the amount the beneficiary is liable to pay towards the allowed amount for the Medicaid or CHIP covered services on the claim, i.e., the beneficiary’s copayment liability, coinsurance liability and deductible liability.
- States should not subtract any payments or discounts that went toward the beneficiary cost sharing liability.
- States should not subtract third party liability toward the beneficiary cost sharing liability.
- States should not subtract beneficiary cost sharing waivers or discounts made by the provider.
- The deductible liability amount should account for previous deductible payments made by the beneficiary that went toward their Annual Deductible when reporting the deductible liability for the covered services on the claim.
Data Elements that Report Beneficiary Cost Sharing Payment Amounts
A beneficiary’s cost sharing payment amount is the amount the beneficiary pays out of their own pocket toward their cost sharing liability. The beneficiary’s cost sharing liability is determined by Medicaid or the MCO negotiated contract and is the amount the beneficiary pays to the provider toward the allowed amount in the form of a copayment, coinsurance, and/or deductible payment for covered services on a claim.
There are five data elements that report beneficiary cost sharing payment amounts (new or renamed as of T-MSIS Data Dictionary V3.0.0): TOT-BENEFICIARY-COPAYMENT-PAID-AMOUNT, BENEFICIARY-COPAYMENT-PAID-AMOUNT, TOT-BENEFICIARY-COINSURANCE-PAID-AMOUNT, TOT-BENEFICIARY-DEDUCTIBLE-PAID-AMOUNT, and COMB-BENEFICIARY-COST-SHARING-PAID-AMOUNT.
- States should separately report the beneficiary paid amount for each type of cost sharing, i.e., the beneficiary’s copayment, coinsurance, and deductible for covered services on a claim.
- For claims where states are unable to determine if the beneficiary paid amount went toward their copayment, coinsurance, or deductible (e.g., the copayment and coinsurance payment amounts are reported as one amount), states should report the Combined Beneficiary Cost Sharing Paid Amount only. In these instances, states should not report beneficiary payment amounts in the individual cost sharing data elements.
- States should include payments made by a beneficiary or their representative (e.g., their guardian).
- States should not include payment amounts made by liable third party/ies, even when these payments may reduce how much the beneficiary owes.
- States should not include waivers or discounts made by the provider.
Provider Waivers of Beneficiary Cost Sharing
There are situations where the amount a beneficiary must pay out of their own pocket toward their cost sharing liability is reduced. One such condition is when the provider of the covered services waives or discounts the beneficiary’s copayment liability.
The COPAY-WAIVED-IND data element in T-MSIS (new as of T-MSIS Data Dictionary V3.0.0) collects instances when the provider waives the beneficiary copayment.
Endnotes
[1] CMS MACBIS T-MSIS Reporting Reminder: Reporting Amounts Paid to Providers in T-MSIS: https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/136886
[2] CMS Technical Instructions: Reporting Financial Allowed Amounts in the T-MSIS Claims Files https://www.medicaid.gov/medicaid/data-and-systems/macbis/tmsis/tmsis-blog/106121
[3] See “Deduction of incurred medical expenses” here: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-435/subpart-I/subject-group-ECFR6418eede7d9fe81/section-435.831
[4] See “Cost sharing” here: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/subject-group-ECFRa3c17d28ea07411/section-447.51
[5] Examples of provider copayment waivers include billing but not collecting the copayment, writing-off copayment amounts, discounting products and services and applying the discounts to the copayment amount, offering copayment cards or coupons to pay the copayment.
[6] The Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), prohibits clinical providers from offering, soliciting, paying, or receiving anything of value in exchange for referrals of Medicaid patients. Discounts are a form of kickback under the Anti-Kickback Statute. Therefore, when a provider regularly waives copays in order to make services seem cheaper to potential customers, he is offering a thing of value. Link: 42 U.S. Code § 1320a–7b: https://www.govinfo.gov/content/pkg/USCODE-2020-title42/pdf/USCODE-2020-title42-chap7-subchapXI-partA-sec1320a-7b.pdf
[7] The False Claims Act 31 U.S.C. §§ 3729, indicates that because Medicaid does not pay claims induced by illegal kickbacks, claims for Medicaid payment where a copayment waiver is designed to induce business as false under the False Claim Act. In addition, a routine waver may indicate that false information about the cost of these services has been provided to the government. Link: 31 U.S. Code § 3729 - False claims: https://www.govinfo.gov/content/pkg/USCODE-2020-title31/pdf/USCODE-2020-title31-subtitleIII-chap37-subchapIII-sec3729.pdf
[8] The Social Security Act Section 1903(r)(1)(F) (https://www.ssa.gov/OP_Home/ssact/title19/1903.htm#:~:text=the%20Secretary%3B%20and-,(F),-effective%20for%20claims) requires that states must be able to produce electronic transmission of claims data consistent with the Medicaid Statistical Information System that are necessary for program integrity, program oversight, and administration. See also the State Health Official Letter (SHO) dated August 10, 2018, SHO# 18-008 RE: Transformed-Medicaid. Statistical Information System (TMSIS). https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/downloads/SHO18008.pdf (PDF, 136.4 KB)