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Patty Helphenstine & Roslyn Thomas, CMS

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Presentation on theme: "Patty Helphenstine & Roslyn Thomas, CMS"— Presentation transcript:

1 Patty Helphenstine & Roslyn Thomas, CMS
Part D-IRMAA Disenrollments & Good Cause Reinstatements An Update of Process and Interactive QA Session Patty Helphenstine & Roslyn Thomas, CMS April 11, 2012

2 Part D-IRMAA Disenrollments
Part D-IRMAA – extra amount in addition to premium Most have IRMAA collected via premium withhold via SSA/OPM RRB direct billing; CMS direct billing for those without premium withhold via SSA/OPM Direct Billing by CMS Monthly billing; always due on 25th of month prior to coverage E.g.: Bill for May coverage due April 25 3 month grace period for non-payment 3 billing months PLUS ~15 days before disenrollment TRRs generated Maintain coverage through end of month

3 Part D-IRMAA Disenrollments
Disenrollments started 4/1/12 First TRRs sent on 3/9 for 3/31/12 disenrollment date Disenrollment effective date is 4/1/12 (1st date w/o coverage) Disenrollments processed monthly Our system processes disenrollment code around 7-10th of the month Expect TRR (TRC 293) around that date Plan sends notice of disenrollment within 10 calendar days Last day of coverage is the end of that month

4 Part D-IRMAA Disenrollments
TRR Issue Alert from MAPD Helpdesk sent on 3/23/12 TRR should include dates in Fields 18 & 24 – only Field 18 populated Field 18 – 1st date individual is no longer enrolled (always 1st of month) Field 24 – last day of individual’s enrollment (always last day of month) Plans use Field 18 to disenroll in their internal systems Last date of coverage should be 1 day prior to date in Field 18 Plan Process Process as involuntary disenrollment; have model Once receive TRC, disenrollment is final – please no additional outreach to affected individuals

5 Part D-IRMAA Reinstatements
CMS will effectuate reinstatements for Part D-IRMAA disenrollment error Wrong individual disenrolled Individual made full payment of all owed amounts timely Individual to call MEDICARE and indicate possible error Verify disenrollment is TRC 293 (failure to pay Part D-IRMAA) Handled using separate process than Good Cause If error, CMS will reinstate individual Plan Process TRR will indicate reinstatement Plan notify individual of access to services

6 Review of Good Cause Basics
Individual requests Good Cause reinstatement via MEDICARE Plan receives request – please refer to 800# Individual must request reinstatement within 60 calendar days of disenrollment effective date (Day 1 = 1st of month w/o coverage) If receive favorable determination from CMS, individual must pay all owed amounts (past due + 3 months of premiums) within 3 months of disenrollment prior to reinstatement If unfavorable and no indication of error, individual remains disenrolled and can make a new enrollment request to any plan at next available election period (AEP, SEP, etc)

7 CMS Process – Triage occurs prior to CTM generation
Good Cause CMS Process – Triage occurs prior to CTM generation Verify disenrollment TRC (plan premiums or Part D-IRMAA) Allegations of error utilize separate process, not continued in Good Cause process Verify disenrollment date within 60 calendar days Receive positive attestation on ability to pay all past due amounts + 3 months of premiums within 3 months of disenrollment Receive positive attestation of unexpected and uncontrollable circumstance occurring 2-3 months prior to disenrollment If all steps are affirmed, CTM is generated with details about individual’s circumstance and routed to CMS caseworker

8 Early implementation identified some lessons learned
Good Cause Early implementation identified some lessons learned CTM categorization and timeliness flags Plan involvement in review of cases Coaching of individuals Improved phone scripts, triage and processing Good Cause CTMs from 800# initially routed to CMS ROs, not plans Only marked “Urgent” when favorable CTM sent to plan for action to notify individual of amount owed within 3 business days and to collect payment REMEMBER: CTM will remain open until payment received or 3 months after disenrollment. NOT counted in timeliness reports or plan performance metrics

9 Improved 800# scripts, triage and processing
Good Cause Improved 800# scripts, triage and processing Established separate process for allegations of plan error If individual alleges plan error with 800# or while providing details of circumstance, CTM goes to plan to address/resolve as plan error If CMS Caseworker obtains additional information from individual alleging plan error after Good Cause CTM was generated, they will reassign the CTM to the plan to resolve possible error CTM summary may have details of other circumstances that sound like Good Cause – still determine if plan error Special process for indication of possible Good Cause request during determination of plan error Plan may reassign CTM to CMS for action as Good Cause IF: - Plan receives CTM for plan error and finds none, AND - Individual makes indication they had good reason for not paying timely CMS RO will triage and handle as Good Cause request

10 Good Cause Plan involvement in Good Cause cases is only once favorable determination is made Please do not coach individuals with forming the accounts of their circumstances Other notable items: Plans may not permit partial payment for Good Cause reinstatements – MUST pay all past due + 3 months Plans may contact individual to remind of payment due date or take payment via phone (EFT, credit card)

11 Good Cause Other notable items:
Plans may provide access to services upon receipt of full payment (if no Part D-IRMAA) Part D-IRMAA cases – MUST wait to provide access to services until receive TRR or approval from CMS caseworker Plans need to update CTM and send to CMS for action so reinstatement can be processed (expectation – within 5 days of receipt of full payment) Plans have option to wait extra days to assure payment clears bank before updating CTM Business decision by the plan, not requirement If subsequently find payment did not clear, work with your Account Manager/Lead Caseworker to remove reinstatement HPMS memo (1/5/12) provided 5 extra days for plans to process and update individual’s account for payments received near or on the last day of the third month.

12 HPMS Memorandums and Notifications:
Resources Guidance Documents: Publication on IRMAA: HPMS Memorandums and Notifications: 5/27/2011 – Part D-Income Related Monthly Adjustment Amount Updates 12/8/2011 – Disenrollment for Failure to Pay Part D-Income Related Monthly Adjustment Amount 3/23/2012 – MAPD Helpdesk Alert on Part D-IRMAA Disenrollment Processing 9/30/2011 – Updated Complaints tracking Modules (CTM) Guidance on Standard Operating Procedures (SOP) 1/5/2012 – Reinstatement Based on “Good Cause” Determinations for Failure to Pay Plan Premiums or the Part D-IRMAA

13 Part D-IRMAA and Good Cause

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