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Back  RFI # 1067: Inactive Covered Individuals

Formal vs. Informal Help Informal Formal


Christopher Gracon


According to CMS regulations on Section 111 of Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA), group health plans are required to report to CMS on active and inactive covered individuals. We are facing a challenge on how to collect all the inactive covered individuals via the 834. As per the CMS guide regarding inactive covered individuals:
"Inactive Covered Individuals are people who are currently not employed (most are carried as retired), and a spouse and (or) other dependents, enrolled in your GHP who cannot be classified as Active Covered Individuals."
The retirees, which are most of the inactive, we can capture via the INS08 = RT. The problem we have is with inactives who are not retired or COBRA. They have active benefits but are not active employees. An example of this would be someone on long term disability who still has employer sponsored coverage. There could be situations other than disability too.
How can this be handled in the 4010 and 5010 834?

Submitter Assigned Keywords

834 Inactive MMSEA Section 111 INS


This issue is explicitly addressed in guide 004010X095A1. INS08 includes multiple Employment Status code values, including code "L1", meaning "Leave of Absence". From a work perspective, the situation identified (long term disability) fits into that category. Any other situations that involve an approved absence from work while benefits are still being provided to the individual also fit into that category. For those scenarios that do not fit into the previous categories cited for the 004010, use the 2300 Loop HD04 to indicate 'INACTIVE'. For the 005010 version, please use the 2700 Reporting Loop to indicate 'INACTIVE.
Submission 6/4/2010
Status Date 6/25/2010
Status F - Final
Primary References
Document 004010X095A1
Set ID834
Secondary References
RFI ID 973
Document 005010X220
Set ID834