1) Question: What dates should be captured in the “Eligibility Start Date” and “Eligibility End Date” fields?
Answer: Start and end dates are used by other PARIS states as a filtering tool for the Interstate match. It is very important to enter both a start and an end date for each program and only submit records that are currently open for a program in your state. In order to create consistency across states, it is recommended that states use one of the following options to determine program eligibility state and end dates:
For the start date use the most recent actual program start date or the program start date of the current certification period. For the end date use the end date of the current certification period
- Example 1: A case is open for Food Stamps and TANF. The Food Stamp program was opened October 12, 2007 and the TANF program was opened May 24, 2008. The next re-certification must be completed by September 30, 2008. For Food Stamps use the start date 20071012 (CCYYMMDD). For the TANF program use the start date 20080524. For both programs use the end date 20080930.
- Example 2: A case is open for Food Stamps and TANF. The Food Stamp program was opened October 12, 2007 and the TANF program was opened May 24, 2008. The last certification was completed in June 2008 and benefits were continued starting July 1, 2008. The next certification must be completed by December 31, 2008. For Food Stamps use the start date 20080701. For the TANF program use the start date 20080701. For both programs use the end date 20081231.
- Example 3: A case is open for Food Stamps and TANF. The Food Stamp program was opened October 12, 2007 and the TANF program was opened May 24, 2008. The certification periods are not the same for both programs. The current Food Stamp certification ends August 31, 2008. The current TANF certification period ends November 30, 2008. Use either methodology in examples 1 & 2 to determine the start date. Use the last date of the certification period for each program for the end date, 20080831 for Food Stamps and 20081130 for TANF.
For the start date use the most recent actual program start date or the program start date of the most recent re-certification (same as first option). For the end date use 99999999 to indicate that the program is still open.
- Example 1: A case is open for Medicaid and Child Care. The Medicaid program was opened November 18, 2007. The Child Care program was opened March 4, 2008. Both programs are still open at the time the PARIS file is submitted. Use 20071118 for the Medicaid start date and 20080304 for the Child Care start date. Use 99999999 for the end date for both programs.
- A case is open for Medicaid and Child Care. The Medicaid program was opened November 18, 2007. The Child Care program was opened March 4, 2008. The last certification was completed April 30, 2008 and benefits were continued as of May 1, 2008. Both programs are still open at the time the PARIS file is submitted. Use 20080501 as the start date for both programs and 99999999 as the end date.
2) Question: How do you locate the group of PARIS Federal file matches that possibly lead to potential TRICARE Third Party Liability (TPL) identification?
Answer: The group that comprises virtually all of the persons eligible for TRICARE may be identified by isolating the ‘Record Type’ (position 130 & 131 on Federal output file) identified as ‘MR’ or ‘MA’ clients. These, including all of the dependents listed in each of their state assistance units (spouse, children etc) are likely TRICARE eligible and already entered in the Federal DEERS (Defense Enrollment Eligibility Reporting System) system. By comparing this group with those already known by your state's Third Party COB (Coordination of Benefits), you will be left with new TRICARE related third party enrollments. These should be sent to the COB office for necessary action. Your state and PARIS related savings may be attributed to and based upon the resulting pre and post Medicaid payments. Keep in mind that your state is entitled to retroactively (up to one year) bill TRICARE for any services that Medicaid paid.
3) Question: What is the process used to identify veterans that are between 70-100% disabled? I heard they were entitled to full VA care and for the most part, shouldn't require Medicaid coverage.
Answer: Veterans that receive disability percent payments may be found in the ‘Entitlement Code’ field (positions 299 & 300 on the VA output file). The second position of this 2-position data field will or should reflect a ‘1’ (compensation). An example of one that you may see in this data field is ‘71’. The first position ‘7’ identifies this to be a Vietnam era veteran. The second position ‘1’ reflects receiving compensation (disability percent related) related benefits. Thus you have a Vietnam veteran that is receiving a monthly disability percent based monthly benefit. Arranging the second position ‘1’ by their gross dollar benefit and beginning with those with the highest monthly benefit, you will be starting with those that are undoubtedly 100% disabled. Click here for a table that lists the usual monthly amounts associated with the respective % of disability. As veterans receive extra dollar amounts associated with loss of limbs etc, the amount listed in the gross may be higher than the base amount found on the table. The VA table should be utilized as a guide.
4) Question: When it is determined that a recipient has received benefits in more than one state in the same month which state pursues the overpayment and/or disqualification?
Answer: The following answer is very general. States should follow up with their own policy specialists and possibly the federal agency that administers the program for which the possible overpayment is alleged for specific clarification. The question has come about mostly because of Food Stamp Simplified Reporting and therefore the information below is based mostly on Food Stamp regulations and clarifications. Also, the question of whether or not an IPV of any type should be pursued for any matter depends on the particulars of each case.
In general it depends on the reporting requirements of the state, specifically if the recipient is required to report if they move (including if they move to another state). When a client applies for benefits in a state and fails to report that they were currently participating in the program in another state, as required by your application, you may pursue an Intentional Program Violation (IPV) because the application was falsified. The claim resides with your state. If the recipient was required to report the move to the state they moved from and did not, that state may also have a potential overpayment and IPV. Thus, if a recipient moves out of your state and is required to report the move timely but does not, your state may also consider pursing an overpayment and IPV because the client failed to report.
5) Question: Can a State disqualify a person and seek restitution/recoupment for receiving Nutrition Assistance Program (NAP) benefits in Puerto Rico and concurrently receiving SNAP benefits elsewhere?
Answer: According to USDA-FNS, States may not count NAP benefits when determining eligibility for SNAP benefits. FNS has also stated that because the two programs are different, there is no justification to disqualify for “duplicate benefits”. Puerto Rico will continue to submit NAP information in the FS (SNAP) field for the Interstate file. States may wish to use this information to assist in determining residency. States are encouraged to contact their regional FNS office for specific clarifications if needed.
6) Question: Because this is a quarterly match, should our state submit individuals that were active on assistance at any time during the quarter, or active as of the date of submission?
Answer: States should only submit individuals that are active in at least one program on the date the data is collected for submission for the quarterly match.
7) Question: Is the submission of state Medicaid information to PARIS restricted by the Health Insurance Portability and Accountability Act (HIPAA)?
Answer: Under the HIPAA Privacy Rule, a state Medicaid agency, either directly or through a contractor, is permitted to share information with another state's Medicaid agency, or a non-Medicaid state public assistance agency, in order to determine recipient eligibility. The Rule does not require a business associate agreement between the agencies (although one would be required between a state Medicaid agency and a contractor working on the agency's behalf).
The Privacy Rule permits covered entities, such as state Medicaid agencies, to disclose protected health information (PHI) for payment purposes without a patient authorization. 45 C.F.R. § 164.506. The definition of payment explicitly includes "activities undertaken by a ... a health plan ... to obtain or provide reimbursement for the provision of health care ... includ[ing] ... determinations of eligibility." 45 C.F.R. § 164.501. Such disclosures are subject to the minimum necessary requirement, meaning that a state Medicaid agency disclosing PHI for purposes of determining recipient eligibility may only disclose the minimum amount of information that is necessary for the eligibility determination. 45 C.F.R. § 164.502(b).
When a state Medicaid agency works with another state agency for purposes of determining recipient eligibility, the other state agency is not acting as a business associate of the Medicaid agency. The regulations address this at 45 C.F.R. § 164.502(e)(1)(ii)(C), providing that the requirement for a business associate agreement shall not apply to:
With respect to uses or disclosures by a health plan that is a government program providing public benefits, if eligibility for, or enrollment in, the health plan is determined by an agency other than the agency administering the health plan, or if the protected health information used to determine enrollment or eligibility in the health plan is collected by an agency other than the agency administering the health plan, and such activity is authorized by law, with respect to the collection and sharing of individually identifiable health information for the performance of such functions by the health plan and the agency other than the agency administering the health plan.
Note that a state Medicaid agency may disclose PHI to another state Medicaid agency for purposes of its own eligibility determination, or for the benefit of the other state Medicaid agency's eligibility determination. This is pursuant to 45 C.F.R. § 164.506(c)(3), which provides that "[a] covered entity may disclose protected health information to another covered entity or a health care provider for the payment activities of the entity that receives the information."). In contrast, if a state Medicaid agency discloses PHI to an agency that is neither a health plan nor a covered health care provider, then the disclosure must be for the payment purposes of the Medicaid agency, not the payment purposes of the recipient agency. A disclosure that is for the payment purposes of a public assistance agency that is neither a HIPAA covered entity or a health care provider would require patient authorization, unless this disclosure is permitted under the public benefits disclosure provision of the HIPAA Privacy Rule.
The public benefits disclosure provision of the HIPAA Privacy Rule, at 45 C.F.R. § 164.512(k)(6), permits the following disclosures:
"(i) A health plan that is a government program providing public benefits may disclose protected health information relating to eligibility for or enrollment in the health plan to another agency administering a government program providing public benefits if the sharing of eligibility or enrollment information among such government agencies or the maintenance of such information in a single or combined data system accessible to all such government agencies is required or expressly authorized by statute or regulation."
"(ii) A covered entity that is a government agency administering a government program providing public benefits may disclose protected health information relating to the program to another covered entity that is a government agency administering a government program providing public benefits if the programs serve the same or similar populations and the disclosure of protected health information is necessary to coordinate the covered functions of such programs or to improve administration and management relating to the covered functions of such programs."