Best Practices

The following States' best practices have been successful in increasing savings:

Filtering For Results

When Pennsylvania conducted its first interstate match we were surprised and overwhelmed to receive more than 12,000 hits just from one state. We knew the data had to be "massaged" before we sent the hits to our local offices for research and action; otherwise we felt certain we would face a revolt from staff. A cursory examination revealed many hits were due to Social Security number data entry errors. For example, it was extremely doubtful that an 8 year old girl and 76 year old man were one and the same. We had also not taken into consideration benefit eligibility dates and determined that we could safely eliminate 100's of hits as there was no overlapping period when an individual received benefits in both states simultaneously.

Our first attempt at running the Veterans Administration (VA) Match was also enlightening as we had nearly 30,000 hits; representing a potential workload nightmare.

As our involvement with data matching and PARIS grew, so did the ways we refined our match data to insure we were working smarter, not harder. What follows is a brief discussion of data filtering techniques used by Pennsylvania and other states.

1. Before and After: Even though the match results are returned after submission very quickly, we are working with a very fluid population. Someone who was active when the data file was submitted may have been closed (due to an out-of-state move, perhaps) subsequent to the file submission. We compare the results of a match against our client database and are able to eliminate cases in this manner.



2. Demographics: When doing the "after" comparison mentioned above, we match on sex, date of birth, and surname in addition to the Social Security number. While some good hits may be lost, many more bad hits are eliminated.



3. Is the income known?: Before we post the VA Match hits for clearance, we compare the VA benefit amount against the known VA income amount. If we are aware of the benefit, we filter out that match. We also filter out Aid and Attendance payments.



4. Matched before?: Not to be critical of others, but numerous complaints from our local staff were received concerning interstate match hits that had been resolved only to have the same hit appear on the next quarterly run. When the new hit was cleared, we learned, anecdotally, that the other state had not taken action on the previous match. To address the concern of our local staff, we filter out interstate match hits that had appeared on the previous quarter's match.



5. Minimums: Some states filter matches based on time frames. For example, if the overlapping period of benefits between two states is less than 2 months, the match is filtered out. Another similar filter removes match hits in which benefits of less than a certain amount, say $50, are involved.

It is understood that filtering may result in good matches not being reviewed. However, since many of us have had adopt a "doing more with less" philosophy, filtering is a good business decision designed to give you the best results when resources are limited. And the folks who have to clear the matches will thank you.

Maximization Of The Paris Veterans Match In Washington State

Review State Code for Treatment of Certain Payments Made by Department of Veterans Affairs

Many veterans and survivors of veterans receive monthly payments from Veterans Affairs (VA). Some of these recipients who need the regular assistance of a caregiver receive an increased amount from VA. This additional amount, added to the regular payment amount, is known as an aid and attendance allowance. (A&A)¹ According to 20 CFR 416.1103, VA allowances for aid and attendance may not be considered income for eligibility purposes.

However, CMS has recognized the aid and attendance allowances from VA payments as third party payments to be applied toward the cost of Medicaid long term care services when paying claims for long term care services. [see Estate of Krueger v. Richland County, Civil No. 940128 (N.D. 1994)] A person is considered to be in need of aid and attendance if the person “is (1) a patient in a nursing home or (2) helpless or blind, or so nearly helpless or blind as to need or require the regular aid and attendance of another person”. 38 U.S.C. 1115(1)(E), 1311(c), 1315(g), 1502(b). See also 38 C.F.R. 3.351(b) and (c). Additionally, Veterans Affairs have established regulations to determine the need for an aid an attendance allowance, which include but are not limited to: living in a nursing home, “inability of claimant to dress or undress”, and having an “incapacity, physical or mental, which requires care and assistance on a regular basis”. See 38 C.F.R. 3.351(c)(2) and 3.352(a). Under the third-party liability payment scheme, a "third party" is broadly defined as "any individual, entity or program that is or may be liable to pay all or part of the expenditures for medical assistance furnished under a State plan." See 42 C.F.R. 433.136(3). The court in Krueger ruled that

“aid and attendance allowances…are provided based on an assessment of the veteran's physical and medical need for them and, when the veteran is in need of, and in fact does receive, nursing home care, that care substitutes for the purpose for which the aid and attendance allowance was designed. When a veteran is in a nursing home, the aid and attendance allowance is paid to cover the exact same services being paid for by the Medicaid program.”

Effective August 2004, the State of Washington implemented a policy change to treat aid and attendance payments to long term care Medicaid recipients as a third-party resource. While aid and attendance is not considered income when determining eligibility and client participation for long term care services, the portion of VA benefit constituting an A&A allowance is applied to offset and reduce the state payment for long term care services provided to a recipient of VA aid and attendance.

Partnership with State Veterans Services Office

Together, the Department of Social and Health Services and the Washington Department of Veteran’s Affairs identify veterans receiving Medicaid benefits (especially long term care benefits) and review their benefit structure. In some cases, clients have full long term care coverage, either through VA, TRICARE² or CHAMPVA³. In other cases, additional benefits are identified, such as aid and attendance allowance and prescription drug coverage, of which the veteran or family members are not aware.

Department of Social and Health Services (DSHS) partnered with Washington State Veteran’s Affairs (WDVA) through two (2) performance based contracts, which measure savings resulting from VA benefits and ensure sustainability. The focus of these contracts are outreach, enrollment and advocacy of VA benefits to expand the number of Medicaid clients receiving VA benefits and maximize the VA benefits to which they are entitled.

One contract between DSHS and the WDVA addresses the need to review current VA benefits for Medicaid recipients and facilitate the enhancement of benefits for clients not receiving maximum entitlement, as well as a plan to identify new applicants who may be entitled to VA benefits.⁴ The other contract pertains to VA medical benefits and the enrollment of Medicaid recipients into the VA health care system.⁵ Also there Medicaid recipients potentially eligible for but not receiving VA benefits. The work to identify these clients and facilitate VA claims will require an agreement and contract separate from the current Performance Based Agreement that enhances benefits for those that are already eligible for and receiving some VA related monetary benefits.

When an increase in housebound/aid and attendance award is necessary, WDVA initiates the process of increasing the entitlements. For the majority of these clients, WDVA acts in the legal capacity of Client Representative. This authorizes WDVA staff to represent the claimant throughout the VA Adjudication process. Claims are developed and processed more expeditiously in this manner. Staff associates within the Seattle VA Regional Office assume the role of “attorney in fact” in regards to VA claims representation. WDVA has access to the Master VA file, which allows for review of client records and assistance to more participants.

Direct VA benefit services and representation increases the awards to the maximum amount possible under law and decreases the amount of time it takes to receive a favorable rating. DSHS will thereby realize an increase in client participation for long term care services, and a correlating decrease in state reimbursement, at the earliest possible date.

Prepare PARIS VA File Data

Importing VA File

It's important to understand and identify the differences between veterans pension, which is based on financial need, and compensation, which is a non-needs-based benefit based on degree of disability or service-connected death. For this reason, it may be helpful to split the two character “Entitlement Code” (starting at element position 467 in the VA File) into two distinct fields or columns. The first position of the Entitlement Code designates the period of service (e.g., WW I, WW II, Vietnam, etc.); the second position the type of benefit (compensation, pension for veteran, pension for survivor, DIC for survivor, etc.). By assigning a distinct code for the VA benefit type, it is easier to group those clients receiving like benefits, which will be helpful in identifying those who are eligible for an increased payment.

Join State Client Data with VA File Records

While the VA File provides a list of individuals associated with state benefits and active VA claims, it does not necessarily provide all the data needed to ascertain which clients should be receiving a greater amount from VA.

It is helpful to add state client data to the VA File, such as financial responsibility (i.e. whether the individual is a direct recipient of state benefits, non-applying spouse, ineligible parent, non-member, etc.), marital status and living arrangement (e.g., at home, in a nursing facility, assisted living, etc.). This information could be retrieved from the state database and compiled with VA File data after the VA File is received. Alternatively, this state data could be included with the state information that is sent to PARIS for data match (a better solution). Element positions 70-127 of the submitted state information allow space for state optional data such as this.

If possible, collect individual client VA income figures from the state database, to compare with income amounts provided by Veterans Affairs. This provides an opportunity to identify those clients with un(der-)reported VA income. Also, this provides a more precise basis for measurement of cost savings due to identification of VA income.

Use PARIS VA File and State Data to Maximize Veterans Benefits

Assemble Groups of Clients Entitled to VA Benefit Increases

With the PARIS VA File and state data, one can sort out the various groups of clients that should be receiving greater monthly payments from Veterans Affairs. For example:

• Recipients of long term care services should receive an additional aid & attendance allowance with their VA benefit. (Aid and attendance entitlement is represented in element position 229 of the VA File). This is an additional amount that should be considered as a third party payment, to offset Medicaid payment for long term care services. Aid and attendance is available to both veterans and surviving spouses, and to those receiving pension or compensation (including widow’s DIC). Any long term care recipients from the PARIS VA File not coded for aid and attendance should be referred to the state or local Veterans Service Office for an enhancement claim. The exceptions to aid and attendance entitlement include: those not married, receiving VA pension, and residing in a nursing facility (they will receive only $90 per month payment); and those receiving 10-20% service-connected compensation (there is no aid and attendance payment available for this group).



• Long term care recipients not living in a nursing facility should not be receiving the reduced $90 / month VA pension. There may be many clients receiving only $90 / month pension that do not reside in a nursing facility, but continue to receive this reduced payment because Veterans Affairs believes them to be institutionalized. This applies to those eligible for VA pension only, not to those clients entitled to compensation, who should continue to receive their compensation rate regardless of living arrangement. These clients not in nursing facilities receiving reduced pensions need to be referred to the state or local Veterans Service Office for enhancement claims.



• Some clients have a VA claim for benefits, but are receiving zero payment. The PARIS VA File provides a Change Reason code (element position 430) which may indicate the reason for non-payment of VA benefits, including Failure to file an Income Questionnaire, Excessive Net Worth, and Whereabouts Unknown. The state or local Veterans Service Office can help determine which clients are correctly not receiving any payment, and file reinstatement claims for the others.



• Some veterans are receiving compensation based on a low degree of service-connected disability, but now have a worsened condition. By collecting diagnostic data from Medicaid medical, institutional, and possibly pharmaceutical claim history, one can compile condition and disease profiles for these veterans receiving lower service-connected compensation rates and long term care services. This may be especially helpful when considering those veterans with Vietnam service, because there are ten diseases presumed by VA to be service-related for compensation purposes for veterans exposed to Agent Orange and other herbicides during that period.⁶

¹ VA also pays a lesser additional benefit, known as housebound allowance, to some veterans and surviving spouses who are need a lower level of care

² TRICARE is the Department of Defense’s worldwide health care program for active duty and retired uniformed services members and their families. TRICARE consists of TRICARE Prime, a managed care option; TRICARE Extra, a preferred provider option; and TRICARE Standard, a fee-for-service option. TRICARE For Life is also available for Medicare-eligible beneficiaries age 65 and over (effective Oct. 1, 2001). See the TRICARE, Military Health System website for more information.

³ Families of veterans who have a 100 percent, permanent disability, or of veterans who died from a service-connected disability, may be covered by CHAMPVA as long as they are not eligible for TRICARE.

⁴ see Appendix A for a copy of this contract (Interlocal Agreement)

⁵ See the VA Health Eligibility Center site for more information. All veterans are potentially eligible for VA medical care, but this effort focuses on veterans who are receiving aid and attendance allowance or service-connected compensation at a 50% disability rating or higher. These veterans need not obtain a prescription from a VA doctor to receive drugs and medicines from VA, but can have their own doctor provide a prescription to the VA pharmacy. See 38 USC 17.1712(d).

⁶ see Federal Benefits for Veterans and Dependents (2004 Edition), Benefit Programs, Disability Compensation. PDF (984 KB)

Maximization of the PARIS Federal Match in Washington State

Using PARIS Federal (Dept of Defense) File Data to Maximize Third Party Liability

PARIS Federal File Includes TRICARE Sponsors and Beneficiaries

The Federal File data received from the PARIS match provides states with useful verification of client gross income from Defense Finance and Accounting Service (DFAS) and Office of Personnel Management (OPM). Additionally, the Federal File data identifies persons eligible for TRICARE military health insurance, which is the Department of Defense’s worldwide health care program for active duty and retired uniformed services members and their families. TRICARE consists of TRICARE Prime, a managed care option; TRICARE Extra, a preferred provider option; and TRICARE Standard, a fee-for-service option. TRICARE For Life is also available for Medicare-eligible beneficiaries age 65 and over. Beneficiaries may receive care at either a Department of Defense military treatment facility or from a TRICARE-authorized civilian provider.

TRICARE provides, among many other benefits, a world-class pharmacy benefit to all Uniformed Service members eligible for TRICARE, including TRICARE for Life (TFL) beneficiaries entitled to Medicare Part A and B. Eligible beneficiaries may fill prescription medications at military treatment facility (MTF) pharmacies; through the TRICARE Mail Order Pharmacy (TMOP); at TRICARE retail network pharmacies; and at non-network pharmacies. To have a prescription filled, beneficiaries need a written prescription and a valid Uniformed Services identification card. They must have their address and other information updated in the Defense Enrollment Eligibility Reporting System (DEERS).

Categories of Eligible TRICARE Beneficiaries include:

• Active duty and retired service members



• Spouses and unmarried children (including stepchildren) of active duty or retired service members. Note: Stepchildren lose eligibility after a divorce unless adopted by the sponsor.



• Reserve Component members on active duty for more than 30 days – under Federal orders



• Spouses and unmarried children of reserve component service members (Covered while reserve component sponsor is on active duty for more than 30 consecutive days).



• Retired reserve component service members and their family members [When the retired reserve component service member is eligible for retirement pay (usually at age 60), the member and his/her eligible family members become TRICARE eligible]



• Widows or widowers and unmarried children of deceased active duty or retired service members.

PARIS Federal File Includes TRICARE Sponsors and Beneficiaries

TRICARE sponsors and beneficiaries are identified in the PARIS Federal File by the Record Type indicators (located at element position 317, following the State data):

RECORD TYPE = CD RECORD TYPE = CO RECORD TYPE = CR RECORD TYPE = MA RECORD TYPE = MR RECORD TYPE = MV RECORD TYPE = NF

DOD CIVILIAN OPM CIVILIAN OPM CIVIL SERVICE RETIREMENT MILITARY ACTIVE DUTY MILITARY RETIRED PAY MILITARY RESERVES NON-APPROPRIATED FUNDS

Active-duty military members, military retirees, and in certain cases, military reservists¹ are eligible for TRICARE health insurance. Family members, surviving spouses and surviving unmarried children are normally also eligible for TRICARE.

It is important to recognize that the PARIS Federal File identifies only the primary recipient of military benefits; it does not list spouses and other family members associated with that individual who may (also) be receiving state medical assistance. Some TRICARE-eligible military personnel identified by the PARIS Federal File are not recipients of state medical assistance (i.e., some are non-applying or ineligible spouses / parents of recipients). In other cases, the TRICARE-eligible individual is receiving state medical assistance together with a spouse and/or other family members.

For these reasons, a complete list of state medical recipients associated with the TRICARE beneficiary / sponsor must be compiled, to ascertain which clients need Third Party Liability profiles updated. This can be done by extracting from the state records an inventory of all medical assistance recipients corresponding to the Case Number (located at element position 133 of the Federal File, in the state data section) of the TRICARE beneficiary / sponsor.

¹ For military reservists, the Category Code (element position 573 in the Federal File, following Pay Status) must correspond to TRICARE eligibility guidelines for the reservist (and family members) to be TRICARE eligible.

Notify State Medical Benefits Coordination of Military TPL

The register of TRICARE-eligible sponsors and family members receiving state medical assistance is forwarded to the state coordination of benefits group for Third Party Liability data update, as needed.

To be eligible for TRICARE, beneficiaries must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS). DEERS is a computerized database of military sponsors, families and others worldwide who are entitled under the law to TRICARE benefits. Active-duty and retired service members are automatically registered in DEERS, but they must take action to register their family members and ensure they’re correctly entered into the database. Enrollment information is available at www.tricare.osd.mil/deers/default.cfm.

The appropriate state medical benefits coordinator confirms DEERS enrollment for the TRICARE sponsor and family members. Once enrollment and eligibility are confirmed, the Third Party Liability profile is updated, which notifies medical providers that TRICARE is to pay covered medical care costs before Medicaid pays a claim.

Identification of TRICARE-eligible Clients Saves Money

TRICARE provides comprehensive health care coverage for the Uniformed Service member and eligible family members. In addition to comprehensive medical coverage, enrolled beneficiaries are also eligible for TRICARE’s pharmacy benefit.

The State of Washington Aging and Disability Services Administration studied pharmacy utilization costs for 107 Long Term Care Medicaid recipients identified by the PARIS Federal File in 2003 as eligible for TRICARE. These clients were referred to the state Coordination of Benefits section, and Third Party Liability (TPL) profiles were updated to reflect TRICARE coverage, which prompted pharmacy providers to tender claims under TRICARE before Medicaid.

Average monthly pharmacy utilization for these clients was $434.09. In the months prior to TRICARE identification and TPL update, Medicaid was paying an average of $223.71 per month (57%) of pharmacy costs.

Contact Information

For more information you may contact:
Tim Dahlin, PARIS/Veteran’s Program Manager
Washington State Department of Social & Health Services
Aging and Disability Services
(360) 397-9542
dahlita@ dshs.wa.gov