MSP WG-2 QMB Program Related Coding

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Medicare Savings Programs Manual

WG-2 MSP and Buy-In Related Coding

Updated 5/28/19

There are 6 basic case descriptors related to the Medicare Savings Programs (QMB/SMB/SMF) they are:

QMB – for cases where there is no other Medicaid eligibility.

QMM – is used for cases with QMB-BAS eligibility and also the Plus medical benefit. For APD this is usually OSIPM, but it could also be MAGI-PCR, MAGI-PWO, or MAGI-CMO.

SMB – for all cases where SMB eligibility exists

SMF – for all cases where SMF eligibility exists. Effective 1/1/17, clients who are receiving any other Medicaid program are not eligible for SMF.

SBI – where a client has Medicare, is a Plus eligible client, but is over income for QMB and SMB. NOTE: SBI can be used on Part B Medicare only clients (MIB = 1) as well as those with Part A (MIB = 2 or 3).

CBI – is for clients who would otherwise be SBI, but have an ongoing paid liability which is larger than their Part B premium. CBI clients are removed from state-paid buy-in and given a like amount deduction. This results in a neutral effect on the client and an enhanced match rate for the state. CBI should not be used for those with EMI as it does not benefit the client. NOTE: CBI can be used on Part B Medicare only clients (MIB = 1) as well as those with Part A (MIB = 2 or 3).

The following case descriptors are used to facilitate our reporting to the federal government which of our clients is subsidy eligible for Part D of Medicare and their level of payment.

There are 3 Part D Medicare-related Case Descriptors. All of these clients receive Part A and/or Part B of Medicare. The codes are:

ISI – Institutionalized Subsidy Individual – full dual-eligible individuals (receiving Medicare and OSIPM) who have resided or are expected reside in a medical institution or nursing facility for at least 30 days. They will have no co-pays for Part D Medicare.

FS1 – a non-institutionalized individual who has income at or below 100% FPL. They will have a co-pay for pharmaceuticals, which changes every January.

FS2 – a non-institutionalized individual who has income above 100% FPL. They will have a co-pay for pharmaceuticals, which changes every January.

Note: Home and community-based service clients have no co-pays, regardless of the FS1 or FS2 coding.

EXAMPLES

Client has OSIPM, in-home waivered services, Medicare Part B and 130% FPL in income.

MIB = 1
C/D = SBI or CBI, FS2 (no MSP code as no Part A).

Client has OSIPM, is in a NF, Medicare Part A & B and 130% FPL in income.

MIB = 3
C/D = SBI and ISI. If the NF will be the client's stable living situation and their paid liability is greater than their Part B premium, they would be CBI instead.

Client has OSIPM, is at home without services, Medicare Part A & B and 110% FPL in income.

MIB = 3
C/D = SMB and FS2

Client has OSIPM, is in a Foster Home, Medicare Part A and 100% FPL in income.

MIB = 2
C/D = QMM and FS1

Important tips for coding clients who receive Medicare :

As of 1/1/17, SMF is a stand-alone benefit, so SMF coding must only appear on a P2 case
Dually-eligible clients in medical institutions or nursing facilities for 30 days or more are ISI regardless of income
All dual eligible clients not in institutions are either FS1 or FS2
All clients coded with QMB or QMM are FS1
All SMB/SMF/SBI clients are FS2
CBI coding IS FOR clients with an ongoing payable liability greater than their Medicare premium. This includes Part B-only clients. It is also for clients whose Part B Medicare premium is paid for by an entity other than the state, such as a pension plan or RRB.
CBI is NOT FOR clients who are: Pickles, EMI, EPD, DACs, cola widows and widowers and ICP clients who are receiving home and community-based services, as none of these clients has a payable liability. This may change if they move to a nursing facility, as they will no longer be exempt from the liability requirement. CBI may be appropriate for these clients if they will be residing for an extended length of time (depending on their income and liability amount).
For clients whose condition leads to their leaving LTC and going to a hospital or rehab setting where they have no liability, make them an SBI client until their condition stabilizes. A generalized rule may be to see three months of non-movement before making them a CBI client. Some clients have a condition that inherently makes their living situation variable; and they should be started/left SBI for the duration of being a client.
Clients with a Medicare premium greater than the base rate (because they delayed picking up Part B, for instance) should be put in SBI for one month, or until the buy-in goes through, then converted to CBI . This drops the Part B premium to the base level and it will stay there.
Some long-term care/waivered service and EPD clients have income that will make the MSP portion of a case go N/A. This is because the CMS system cannot adjust income for MSPs on a long-term care or EPD case and simultaneously determine a liability or Participant Fee. In these situations, the N/A message on Oregon ACCESS is only a warning that CMS thinks the case is over income for the MSP you have selected. The MSP is still valid, and the case will still go through Buy-In.
Some MAGI clients can also be eligible for Medicare Savings Programs (MAGI-PCR, MAGI-PWO, MAGI-CMO). For QMB eligible MAGI clients just add the QMM and FS1 codes to their case. For SMB with PCR, CMO, or PWO, there is a problem with MMIS. It will not accept the SMB or FS2 coding and will not accept a separate P2 case for the SMB. The current solution is to call the buy-in unit to start that process. There is no Medicare Savings Program (MSP) related coding put on the case and MIB is left at 0. Medicare is coded on the MMIS panels, a reduction notice needs to be sent to the client and help with Part D enrollment offered. For PWO cases, sixty days after the birth the case will be re-coded as appropriate and the MSP and MIB coding added.
For couples who are both in non-standard living arrangements and are residing in the same community-based-care facility, the liability will not be calculated correctly if the spouse is on the case and coded with income. That means the worker must adjust the coding and narrate what they did and why. For example: I left Mrs. A’s income off of the case so the liability would calculate correctly. Her income added to Mr. A’s totaled $XXX.XX which is under the two person standard for QMB. I coded 2 in med pgm/# and HH fields to show she was in need group for the QMB program.

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