Department of Civil Service

PA95-12

TO: Participating Agency Health Benefits Administrators
FROM: The Employee Benefits Division
SUBJECT: Implementation of MediPrime Rates
DATE: November 17, 1995

The Division is currently implementing MediPrime Rates for Participating Agencies. As explained in the Empire Plan Quarterly Report dated September 14, 1995 (PA95-1O), beginning January 12, 1996, Medicare primary persons enrolled through your agency will be charged a premium that reflects their favorable Program experience. To be able to charge the appropriate premium, it is necessary to identify each person who is Medicare primary and indicate that status on the enrollment record.

This memorandum provides you with:

• Background information on how we determined who was eligible for MediPrime status and a list of the actions taken to initialize the MediPrime status on the enrollment records of your agency's employees and retirees,
• Instructions on how to verify and correct the status assigned to your enrollments and on how to maintain MediPrime status information in the future, and
• Updated pages for the HBA Manual.

Background

To initially determine MediPrime status, the Division matched its enrollment information to that of Medicare. However, because data differences between the two files may have caused a significant understatement of the number of Medicare primary individuals in the program, MetraHealth was asked to provide the Division with a tape of the persons for whom a Medicare primary claim was filed during the last twelve months. The Division used the results of these two matches to determine both the enrollees and the dependents eligibility for MediPrime status. The Central Enrollment File will be updated for all Medicare eligible enrollees and dependents appearing on the enclosed report. This process will also be used to remove the Medicare status indicator (USF) for enrollees or dependents who did not meet the match criteria.

The rates you pay in 1996 and claim payments will be based on the addition or deletion of this MediPrime status indicator. Therefore, it is important that you verify the initial enrollment settings and that you maintain accurate Medicare eligibility information on the Central File.

Because your agency will be paying lower rates on behalf of MediPrime enrollees, it is now necessary for you to keep accurate records of enrollee's and dependent's Medicare eligibility and whether Medicare is primary coverage. You must have in your files proof of each MediPrime enrollee's and dependent's Medicare eligibility. These records are subject to audit by this Division. Appropriate documentation would include a copy of the Medicare card or Social Security Administration letter indicating Medicare coverage.

Instructions for Validating Information on the MediPrime Reconciliation Listing

Enclosed is the listing of persons for whom MediPrime Status has been assigned and those persons for whom your agency submitted a USF transaction in the past but for whom Medicare primary status could not be confirmed. This listing reflects changes to the file and MediPrime eligibility up to November 3, 1995, the date the Central Enrollment file was initialized.

Because the MediPrime Status is tied to the premium your agency will pay in 1996. it is important that you confirm the current Medicare status of each person enrolled through your agency.

Initially, a MediPrime premium will be charged only for those enrollees and dependents for whom MediPrime status is reflected on the Central Enrollment File on the date the November Cycle Report is produced. The MED and RMD transactions will be available for agency processing after the production of the November Cycle Report. Corrections, additions and deletions processed after the November Cycle Report is produced will be reflected on future cycle reports. In all cases, the effective date of the MediPrime status will be the later of January 12,1996, or the effective date of the Medicare primary status.

To reconcile your enrollment to the list:

1.Confirm that each person listed as having been "added" to MediPrime status has Medicare primary coverage. You can confirm this by reviewing your records and identifying persons to whom you have been reimbursing Medicare Part B premium. If your records are incomplete you will need to contact the enrollee and obtain a copy of his/her Medicare card.

Please keep in mind that a person who is Medicare eligible may not have Medicare primary coverage. The Medicare eligible spouse of an active employee, for example, is plan primary and would not qualify for MediPrime status. The rules for determining who is Medicare primary and who is plan primary can be found in Section 6120 of your manual. If, after reading this Section, you are still unable to determine whether Medicare coverage is primary, please call or write the Division.

2. Confirm that each person, if any, listed as having been deleted from MediPrime status is Plan primary. Such persons will have been reported to the Central File as having been Under Sixty Five (65) Medicare (USF) eligible at some time in the past but did not match with an enrollment on the Medicare file and did not have a claim in the last twelve months which was accompanied by a Medicare Explanation of Benefits (EOB). These enrollees and dependents will be considered Plan primary unless you submit a transaction to update their records to MediPrime status.

3. Confirm that all enrollees and dependents which your records list as Medicare primary are included in the Reconciliation Listing. Any Medicare eligible person not included in the listing will need a transaction to the Central Enrollment File to update the MediPrime status indicator.

If you are uncertain as to the correct status, call your processor.

Once again, please remember that effective with the MediPrime rates no claims will be paid by the Empire Plan carriers when conflicting information is present. A claim received on behalf of an enrollee or a dependent whose enrollment indicates MediPrime Status will not be paid unless it is accompanied by a Medicare EOB.

Maintaining MediPrime Status for Your Enrollees

Adding MediPrime Status

MediPrime status is added by using the MED transaction. Use the Monthly Medicare Eligibility Report to identify persons who are becoming Medicare Eligible due to age. Contact each enrollee on the report and remind them that they must enroll in Medicare Part B if they are eligible and retired. Spouses of retirees must also enroll in Medicare whether the spouse is actively employed or retired. Have them provide you with a copy of their Medicare card as soon as they receive it. Because the report identifies persons turning age 65 during the third month following the month in which the report is produced, you will have sufficient time to obtain a copy of the card and still submit the MED transaction in time to update the correct cycle report.

In addition to the persons listed on the report you may become aware of other enrollees or dependents for whom Medicare Coverage is primary. If the person is over age 65, submit a MED transaction at the appropriate time. If the person is under 65 then complete a PS 503.1 with the MED transaction and send it, along with a copy of the person's Medicare card, to the Employee Benefits Division. Mark the envelope "PA/PE Unit".

In no case is MediPrime Status automatically granted based on another transaction you submit. You must, in all cases, complete and submit an MED transaction to the Central File.

Removing MediPrime Status

MediPrime Status is removed by using the RMD transaction. Remove MediPrime Status whenever a person who was Medicare primary becomes plan primary. This will occur, for example, whenever a Medicare primary retiree returns to work in a position which is eligible for health insurance.
MediPrime Status is automatically removed whenever you submit a transaction which deletes coverage for the enrollee or a dependent who was Medicare eligible. A CCO to Individual coverage will end the MediPrime Status for any dependents. A DEL will remove it only for the person being deleted.
Instructions for completing the MED and RMD transactions are enclosed.

Changes to the Information Listings and Cycle Reports

As a result of the implementation of MediPrime Rates both the Information Listing and the Cycle Report have been revised. Information on these revisions will be sent to you under separate cover.

New York State Government Employees'
Health Insurance Program

Manual for Participating Subdivisions

PROCESSING TRANSACTIONS
Medicare Eligible - "MED"
Loss of Medicare Eligibility - "RMD"

Complete a Health Insurance Transaction Form (PS-503.1)

"MED":

An "MED" transaction is used when an enrollee or dependent meets the following criteria: a) eligible for medicare primary coverage (refer to Section 610), b) enrolled in Medicare Part B and c) is over the age of 65. An "MED" for enrollees or dependents who are under the age of 65 must be processed by the Employee Benefits Division (forward a completed 503.1 along with a copy of the Medicare card to EBD for processing).

The agency representative must obtain from the enrollee or dependent a copy of the Medicare Card in order to verify enrollment in Medicare Part B. The copy of the card should be attached to the agency copy of the transaction form.

One transaction form must be completed for each Medicare eligible person. For example two "MED" transaction forms are needed when both the enrollee and the spouse are eligible for Medicare Part B coverage.

The employee completes sections 1 and 4 as follows:

Section 1:

Complete items 1 through 7.

Section 4:

Item 17 - If the person eligible for Medicare benefits is other than the enrollee, the name (last name, first name, and middle initial), relationship, and date of birth of the dependent must be entered in item 17 and circled in red.
If the person eligible for Medicare benefits is the enrollee, the name (last name, first name, and middle initial), "self" for relationship, and date of birth of the enrollee must be entered in item 17 and circled in red.
Item 18 - The enrollee must sign and date the form.

The agency representative completes section 5 as follows:

Item19 (transaction code) - Enter "MED"
Item 20 (effective date) - Enter the date on which Medicare Part B coverage becomes primary (refer to Section 610) for the enrollee or dependent.
Items 21, 22, and 35 - Enter the agency code, agency name, and sign and date the form.

New York State Government Employees'
Health Insurance Program

Manual for Participating Subdivisions

PROCESSING TRANSACTIONS
Medicare Eligible - "MED"
Loss of Medicare Eligibility - "RMD"

Complete a Health Insurance Transaction Form (PS-503.1)

"RMD":

A "RMD" transaction is used when an enrollee or dependent changes status and is no longer Medicare primary (Refer to section 610). It can also be used when the "MED" was done in error. NOTE: This transaction is not necessary if the "MED" transaction was never done.

One transaction form must be completed for each person who lost Medicare eligiblity. For example two "RMD" transaction forms are needed when both the enrollee and the spouse lose eligiblity.

The employee completes sections 1 and 4 as follows:

Section 1:

Complete items 1 through 7.

Section 4:

Item 17 - If the person losing eligibility fore Medicare primary benefits is other than the enrollee, the name (last name, first name, and middle initial), relationship, and date of birth of the dependent must be entered in item 17 and circled in red.

If the person losing eligibility for Medicare primary benefits is the enrollee, the name (last name, first name, and middle initial), "self" for relationship, and date of birth of the erollee must be entered in item 17 and circled in red.

Item 18 - The enrollee must sign and date the form.

The agency representative completes section 5 as follows:

Item 19 (transaction code) - Enter "RMD".

Item 20 (effective date) - When the "MED" was done in error, the effective date should be the same as the effective date on the "MED". In all othen cases, the effective date is the last day of the month in which the enrollee or dependent loses eligibility.

Items 21, 22, and 35 - Enter the agency code, agency name, and sign and date the form.