Claims Processing Requirements for Medicare Deported Beneficiaries


Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation.  Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if there is no monthly benefit payable under Title II.  Section 1836 of the Act limits Part B benefits to those who are either entitled to Part A benefits or who are age 65 and a United States (U.S.) resident, U.S. citizen, or a lawfully admitted alien residing permanently in the U.S.  Given that, a deported beneficiary is not allowed to enter the U.S. and cannot be lawfully present in the United States to receive Medicare-covered services, Medicare payment cannot be made for Part B Benefits.


An audit of Medicare payments by the Office of Inspector General identified a vulnerability for the Medicare trust fund with respect to this issue.  The study identified improper payments for beneficiaries, who, on the date of service on the claim, had been deported.  To address this vulnerability, CMS is establishing claim level editing using data from the Social Security Administration (SSA).  Specifically, the data contains the name and Health Insurance Claim (HIC) of the Medicare beneficiary and the month the deportation is effective.  CWF will reject claims where the effective date on the Master Beneficiary Record is equal to or greater than the date of service on the claim.  All claims rejected by CWF shall be denied by the respective Carrier, DMERC, RHHI or intermediary that submitted the claim to CWF.
Policy:

Medicare payment shall not be made for an item or service furnished to an individual that has been deported from the United States.


Appeals: A party to a claim denied in whole or in part under this policy may appeal the initial determination on the basis of the deportation status at the time the item or service was furnished.

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