National Government Services, Inc. Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter

Capturing Days on Which Medicare Beneficiaries are Entitled to Medicare Advantage (MA) in the Medicare/Supplemental Security Income (SSI) Fraction

Provider Types Affected
Hospitals billing either a Medicare Administrative Contractor (A/B MAC) or fiscal intermediary (FI) for services provided to Medicare beneficiaries enrolled in a Medicare Advantage plan  

Provider Action Needed
This article is based on Change Request (CR) 5647, which states that, as of January 7, 2008, hospitals (this includes acute care hospitals paid under the inpatient prospective payment system, inpatient rehabilitation facilities (IRF), and long term care hospitals (LTCH)) must begin to submit “no pay” bills to their Medicare contractor for stays by Medicare Advantage (MA) beneficiaries. This will allow for the days of those stays to be eventually captured in the DSH (or low income patient (LIP) for IRF) calculations.  

Background
Change Request 5647 states that part of the calculation used to determine whether or not a hospital is eligible for Medicare Disproportionate Share (DSH) payments is based on the percentage of Medicare days for which the beneficiary was entitled to Medicare Part A and received SSI payments from the Social Security Administration (SSA). The SSA provides the SSI information to the Centers for Medicare & Medicaid Services (CMS). CMS then pulls all of the Medicare days for each eligible hospital and determines the percentage of days for which the Medicare beneficiaries were simultaneously eligible for SSI and Medicare. The Medicare beneficiary days should include MA days in addition to Medicare fee-for-service Part A days.

• In the past, hospitals were required to submit this information for MA beneficiaries (through 1998) by submitting a no-pay bill.
• Later, managed care organizations (MCO) (now MA companies) were responsible for submitting this information (through 2001) as part of encounter data submissions to CMS. Since MCOs are no longer required to submit encounter data, hospitals must submit data on their MA days so that these days may be considered in the Medicare fraction of the DSH calculation. The IPPS regulations on DSH are located in 42 CFR 412.106.
• The Inpatient Rehabilitation Facility (IRF) PPS regulations on the Low Income Payment (LIP) are located in 42 CFR 412.624(e)(2).

Key Points of CR5647

• Hospitals may go back and submit claims with discharge dates on or after October 1, 2006 (FY 2007), so that SSI data for FY 2007 and beyond will include MA patient days.
• Hospitals should bill claims on an 11X TOB, include Condition Code 04, and all other applicable claim information because patients who are enrolled in Medicare Advantage (administered through Medicare Part C) should also be included in the Medicare fraction. These days will be included in the Medicare/SSI fraction, but in order for them to be counted, the hospital must submit a no-pay bill (TOB 11X) which includes Condition Code 04 to their Medicare contractor. This will ensure that these days are included in the IRF’s SSI ratio for Fiscal Year 2007 and beyond.
• Teaching hospitals are already submitting their claims with Condition Codes 04 and 69 in order to be reimbursed for their Indirect Medical Education payment. They will continue to submit their bills with Condition Codes 04 and 69.
• To ensure that hospitals’ MA days are included in the FY 2007 Medicare/SSI file (due in the summer of 2008), hospitals should try to submit their FY 2007 claims to their Medicare contractor between the implementation date (January 7, 2008) of this CR through March 2008.
• The Supplemental Security Income (SSI)/Medicare Beneficiary Data for IPPS hospitals is located at http://www.cms.hhs.gov/AcuteInpatientPPS/05_dsh.asp#TopOfPage on the CMS Web site.

Implementation Date
January 7, 2008  

Additional Information
For complete details regarding this Change Request (CR) please see the official instruction (CR5647) issued to your Medicare FI or A/B MAC. That instruction may be viewed by going to http://www.cms.hhs.gov/Transmittals/downloads/R1311CP.pdf on the CMS Web site. The revised sections of the Medicare Claims Processing Manual related to this issue are attached to CR5647.

If you have questions, please contact your Medicare FI or A/B MAC at their toll-free number which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5647
Related Change Request (CR) #: 5647
Related CR Release Date: July 20, 2007
Effective Date: October 1, 2006
Related CR Transmittal #: R1311CP
Implementation Date: January 7, 2008