Reporting Health Insurance Premium Payments in the T‐MSIS OT File (Claims)

Guidance History

Brief Issue Description

This guidance document outlines the specifications for reporting health insurance premium payments (HIPP) (AKA premium assistance subsidy payments) on the OT file. The specifications in the guidance provide a detailed explanation on how the data elements should be populated to ensure premium payments are uniquely identifiable in states’ T-MSIS file submissions.

Background Discussion

Context

Medicaid services have historically been provided primarily on a fee-for-service basis paid directly by the state Medicaid agency or through managed care organizations that contract with the state. Many states have expanded, or have plans to expand, assistance that allows beneficiaries to purchase health insurance on the private market. As health insurance premium payments are becoming more common, accurate representation of these payments in the T-MSIS data is critical.

Challenge

Most states did not report premium assistance payments in MSIS and no specific guidance was ever released. In both MSIS and T-MSIS, a TYPE-OF-SERVICE (COT186) value “121” Premium payments for private health insurance is available to identify a record as a premium assistance payment. These payments typically would be reported with the same TYPE-OF-CLAIM (COT037) value as a capitation payment to a managed care organization (“2”, “B” or “V”).  However, reporting premium assistance payments as a capitation payment has limitations since the premium assistance payments could be made on behalf of more than one beneficiary. For example, a policy could cover a parent and two children, so a single premium assistance payment would cover three beneficiaries, not all of whom are necessarily eligible for Medicaid.

CMS Guidance

A payment that cannot be attributed to a single beneficiary is called a Service Tracking Payment in T-MSIS. The documentation in Table 1 (PDF, 183.47 KB) specifies guidance for reporting premium assistance payments in the OT file. The table specifies the data element name, the data element number, the value populated in the data element, and further explanation of how the field should be populated under this circumstance. A separate claim line record segment (CLAIM-LINE-RECORD-OT-COT00003) should be reported for each beneficiary covered by the insurance policy.

The guidance in Table 1 (PDF, 183.47 KB) focuses on data elements that are specifically germane to premium assistance payments and is not exhaustive. Specifications are provided for reporting cases in which there is a single beneficiary and cases with multiple beneficiaries. Other fundamental data elements such as adjudication date, internal control numbers, and line numbers are still expected to be populated consistent with reporting service tracking payments. See T-MSIS Data Dictionary Appendix P.02 for additional information.

Premium assistance payment for a policy that only covers a single Medicaid or CHIP beneficiary should be reported in a manner more consistent with the way a managed care capitation payment is reported, with the exception of the plan ID reported on a premium assistance payment. Individuals enrolled in premium assistance are not expected to have a corresponding managed care enrollment reported in the eligibility file because it does not meet the definition of managed care in federal statutes and regulations therefore there would be no plan ID reported on the premium assistance payment, whether it be for a policy that covers one person or multiple people.