The Empire Plan is a unique health insurance plan designed especially for public employees in New York State. Empire Plan benefits include inpatient and outpatient hospital coverage, medical/surgical coverage, Centers of Excellence for transplants, infertility and cancer, home care services, equipment and supplies, mental health and substance abuse coverage and prescription drug coverage.
GOVERNOR
DEPARTMENT OF CIVIL SERVICE
ALBANY, NEW YORK 12239
www.cs.ny.gov
COMMISSIONER
DANIEL E. WALL
EXECUTIVE
DEPUTY COMISSIONER
PA97-01
TO: Agency Health Benefits Administrators
FROM: Employee Benefits Division
SUBJECT: "MED" Revision and New "CRI" Transaction
DATE: March 7, 1997
As explained in memo PA95-12 sent in November of 1995, a "MED" transaction should be processed for any enrollee or dependent who is eligible for Medicare primary coverage, in order to allow the correct Mediprime rate to be charged. An "RMD" transaction is processed to change the enrollee's file when either the enrollee or their dependent is no longer Medicare primary. The "MED" transaction has now been updated to include an indicator that identifies whether or not the enrollee or his/her dependents are reimbursable for Medicare under New York State Health Insurance Program rules (see Section 610 of your manual). For example you are not required to reimburse an enrollee for his/her spouse's Medicare when that spouse receives reimbursement elsewhere. Remember you must do a "MED" for all enrollees and their dependents regardless of whether they are to be reimbursed, so claims are paid correctly and you are billed at the correct rate.
Enclosed are new pages for your PA manual to replace the current instructions for the "MED" transaction. Also, enclosed are instructions for a new transaction called a "CR"'. This transaction allows you to change an enrollee's or dependent's reimbursable status once a "MED" has been processed.
Enclosed is a small supply of the newly revised PS-503.1 transaction forms. Please be aware that this new form must be used for any "MED" or "CRI" transactions submitted after March 17. Any "MED" or "CR"' transactions processed on the old forms after this date will reject for lack of a reimbursability indicator. You may order an additional supply of PS-503.1 forms on your order form as needed.
Additionally the agency reconciliation form has been revised to show the Medicare reimbursability of your enrollees and their dependents. A column has been added that lists "Y" for reimbursable and "N" for nonreimbursable. This should make it easier for you to identify your reimbursable enrollees when you prepare your Medicare reimbursement payments. A reconciliation listing can be requested for your agency at any time by contacting the PA/PE Processing Unit.
If you have any questions regarding these transactions please contact the Processing Unit at 518-457-5766, or 518-485-1186, or 518-457-5847.
New York State Government Employees Health Insurance Program
Manual for Participating Subdivisions
PROCESSING TRANSACTIONS
Change Reimbursable Indicator - "CRI"
PURPOSE OF THE "CRI"
The "CRI" transaction is used to change the reimbursable indicator for an enrollee or a dependent record. It is used to correct or update the selection of either "reimbursable" or "not reimbursable" that was made on a previous "MED" transaction. The "CR"' is always used after an "MED" has been processed; it is not intended to be used to add an enrollee's or dependent's reimbursable status when an "MED" has not been done. When an "RMD" transaction is being done to show that Medicare is no longer the primary coverage, the reimbursable indicator is also changed to 'not reimbursable." In this case, a "CRI" transaction is not required.
In general, an enrollee or a dependent who is both eligible for Medicare and has enrolled in Medicare is entitled to a reimbursement of the usual cost of Part B. However, there are exceptions, such as a dependent who is reimbursed elsewhere, that eliminate your obligation to reimburse the Part B cost. In these cases the selection of "not reimbursable" is made. See Section 610 for further information.
One transaction form must be completed for each enrollee or dependent whose reimbursable indicator needs to be changed. For example two PS-503.l transaction forms are needed if both an enrollee and a spouse need to be changed to "not reimbursable."
HOW TO COMPLETE THE PS-503.1
The employee completes sections 1 and 4 as follows:
Section 1:
Complete items 1 through 7.
Section 4:
Item 17 - If the person whose reimbursment status has changed 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 whose reimbursment status has changed 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:
Item 19 - (transaction code) - Enter "CRI".
Item 20 - (effective date) - Enter the same effective date as the original "MED" transaction if this is a correction of the reimbursable status on the "MED." Otherwise the effective date is the first day of the month in which the enrollee or dependent receives or no longer receives reimbursment from another source.
Item 27 - (reimbursable Indicator) - Select either "yes" or "no" depending on whether this enrollee or dependent is eligible tor Medicare Part B reimbursement.
Items 21, 22 and 35 - Enter the agency code, agency name, and sign and date the form.
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), and b) 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. An "MED" should be processed for all enrollees and dependents who are eligible for Medicare, regardless of whether they have enrolled in Part B. Those who are eligible, but choose to not enroll are not entitled to a Medicare reimbursement (the "MED" would be processed with "NO" checked under the reimbursability indicator-see item 27 instructions below).
One transaction form must be completed for each Medicare eligible person. For example two 503.1 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
The agency representative completes section 5 as follows:
Item 19 (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.
Item 27 (reimbursable Indicator) - Select either "yes" or "no" depending on whether this enrollee or dependent is eligible for Medicare Part B reimbursment from your agency (refer to Section 610).
Items 21, 22 and 35 - Enter the agency code, agency name, and sign and date the form.
REVISED 3/7/97