Technical Instruction History
|Date||Description of Change|
|9/25/2017||Original technical instruction issued|
|8/2/2021||Technical instruction language updated to clarify the expectation that MEDICAID-PAID-AMT at the line-level only needs to sum to TOT-MEDICAID-PAID-AMT at the header level when PAYMENT-LEVEL-IND is “2”, indicating that the claim payment was determined at the individual claim lines, in alignment with changes to validation rules deployed on 7/23/21.|
Brief Issue Description
This document outlines the specifications for reporting the amount the Medicaid agency or managed care plan pays towards a beneficiary’s Medicare coinsurance and deductible amount in the T-MSIS claims files. The specifications in the technical instructions provide a detailed explanation on how the data elements should be populated to ensure Medicare coinsurance and deductible amounts are identifiable in states’ T-MSIS file submission.
Medicaid beneficiaries who also qualify for Medicare coverage are known as “dual” eligible or just “duals”. Claims for duals are typically first billed to Medicare and then to Medicaid. Medicare calculates and deducts contractually allowable charge, deductible, and/or coinsurance and pays the remainder. Then when the claim is subsequently sent to Medicaid, as the payer of last resort, Medicaid then typically determines its own contractually allowable charge amount, deducts the Medicare payment, and determines how much of the remaining allowable charges Medicaid is contractually obligated to pay the provider on behalf of the beneficiary for their deductible and/or coinsurance and how much of the deductible and/or coinsurance the provider is contractually obligated to write-off. Note that from Medicare’s perspective, the entire annual deductible amount must be incurred before coinsurance becomes applicable or Medicare makes a payment. Typically once a deductible has been incurred in full for a given type of benefit no more deductible is applied for the rest of the calendar year for that type of benefit, only Medicare payments or coinsurance. Claims billed to the Medicaid program for the beneficiary’s Medicare deductible and/or coinsurance are referred to as crossover claims.
States face two primary challenges when reporting to T-MSIS the amount the Medicaid agency paid towards the Medicare coinsurance and deductible payment. The first challenge is that some states report to T-MSIS the entire amounts that Medicare applied to coinsurance and/or deductible instead of the amounts that the Medicaid agency actually paid towards them after calculating the Medicaid contractual obligation, which are frequently different values. States also face challenges reporting payment information on crossover claims when the payments towards either the coinsurance and/or deductible are not explicitly tracked in the state’s system as anything more specific than the state’s obligation to pay the provider anything.
CMS Technical Instruction
The Medicare coinsurance and Medicare deductible amounts can be reported in T-MSIS under four data elements: MEDICARE-COINS-AMT, MEDICARE-DEDUCTIBLE-AMOUNT, TOT-MEDICARE-COINS-AMT, and TOT-MEDICARE-DEDUCTIBLE-AMOUNT (See Table 1 below for specific data element numbers). The fields should capture the amount paid by Medicaid to the provider not the amount Medicare applied to coinsurance and/or deductible. Therefore, the sum of the amount paid towards the coinsurance and deductible amount is expected to be equal to the Medicaid paid amount in T-MSIS.
For each claim header, states should report the amount paid by the Medicaid agency toward the claim’s total Medicare coinsurance and deductible using the data elements TOT-MEDICARE-COINS-AMT and TOT-MEDICARE-DEDUCTIBLE-AMT, respectively. If the state is unable to separate the coinsurance payment from the deductible payment, the MEDICARE-COMB-DED-IND field should be reported with the valid value of ‘1’. In addition, the TOT-MEDICARE-COINS-AMT field should be spaced-filled or missing and the combined coinsurance and deductible payment amount should be reported in the TOT-MEDICARE-DEDUCTIBLE-AMT. If payment for a crossover claim is determined at the claim header level (PAYMENT-LEVEL-IND=1), MEDICAID-PAID-AMT at the line level does not need to be populated, but TOT-MEDICAID-PAID-AMT at the claim header level should be populated with the total amount paid on the crossover claim.
On the RX file, Medicare coinsurance and deductible amounts can be reported at the line level. If crossover payments for coinsurance and deductible are adjudicated at the line level (PAYMENT-LEVEL-IND=2), states should report the amount paid by the Medicaid agency toward the claim line’s Medicare coinsurance and/or deductible using the data elements MEDICARE-COINS-AMT and/or MEDICARE-DEDUCTIBLE-AMT, respectively. If the state is unable to separate the coinsurance payment from the deductible payment, the MEDICARE-COMB-DED-IND field should be reported with the valid value of ‘1’. In addition, the MEDICARE-COINS-AMT field should be spaced-filled or missing and the combined coinsurance and deductible payment amount should be reported in the MEDICARE-DEDUCTIBLE-AMT. If more than one claim line is reported and claim payment is determined at the line level, then sum of the MEDICAID-PAID-AMT values reported at the claim line level should equal the TOT-MEDICAID-PAID-AMT reported at the header level.
Table 1 - Crossover Claim Data Elements
|Data Element Name||Claim Level||Data Element Number|
 Most RX records are typically reported with one claim line per claim header record. In these cases, the claim line and the claim header paid amounts would be the same.