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Back  RFI # 508: Active & Inactive eligibility

Formal vs. Informal Help Informal Formal

Submitter

KEN EDICK

Description

Is it allowable for a payer to report both an inactive eligibility EB*6 and an active eligibility EB*1 in the same response?

A Medicaid is returning in a 271 an inactive EB segment and then sending an active EB segment (EB*1***QM) when the recipient only has a QMB benefit. When asked why they're indicating inactive eligibility but active for QMB, the Medicaid responds that since the QMB benefit is only paying the Medicare premium, Medicaid isn't paying anything to the 270 submitter.

Another variation by a Medicaid is the following, EB*6**30*HS*MEDICARE PREMIUM PAYMENT ONLY, which the provider is supposed to interpret to mean that the recipient has a QMB benefit.

My suggestion is for the Medicaid to send an EB segment for active coverage with the insurance type of QM (EB*1***QM) instead of MC when the recipient only has a QMB benefit. Is this approach optimal?

Submitter Assigned Keywords

271 QMB Medicaid

Response

Qualified Medicare Beneficiary - QMB (EB04 = QM) and Special Low Income Medicare Beneficiary - SLIMB (EB04 = HS) are two separate types of Medicaid programs.

It is appropriate if Medicaid is the information source to indicate that the individual has Inactive Medicaid Coverage and to indicate that the individual has Active QMB or SLIMB coverage, since both programs may cover the patient’s portion of responsibility (Deductible, co-payments, etc.) and Medicaid is responsible for paying these items.

If a patient has QMB or SLIMB coverage, the initial claim would be filed to Medicare, and a secondary claim would either automatically be crossed from Medicare to Medicaid, or upon receipt of payment from Medicare, the provider would file a secondary claim directly to Medicaid to recover the patient’s portion of responsibility.

The approach that Medicaid is taking is appropriate and compliant with the IG.

Recommendation

See: http://www.cms.hhs.gov/apps/firststep/content/medicare_dualelig.html
or
http://www.cms.hhs.gov/DualEligible/
for details on these programs.
Submission 1/11/2007
Status Date 3/14/2007
Status F - Final
Primary References
Document 004010X092
Section3.1
Page219
Set ID271
Table2
Loop2110C
Segment Position130
Segment IDEB
Element Position01
Industry NameEligibility or Benefit Information