Important Take-Aways from CMS' PAID Act Webinar

Just yesterday on Wednesday, June 23, 2021, the Centers for Medicare & Medicaid Services (CMS) hosted a webinar on the Provide Accurate Information Directly (PAID) Act.

Overview of Presentation by CMS

After providing an overview on the Medicare Secondary Payer (MSP) Act, CMS provided background on the PAID Act:

• Non-Group Health Plan (NGHP) Responsible Reporting Entities (RREs) did not have a reliable way to identify if a beneficiary had a Part C or Part D plan.
• It is estimated that 1 out of 3 beneficiaries have a Part C plan and 9 out of 10 have some form of Part D.
• MSP industry stakeholders pushed for the PAID Act to help them get access to the Part C and D data.
• The PAID Act was signed into law on December 11, 2020.
• The intention of the PAID Act is to help NGHP RREs better coordinate benefits by providing them with Part C and Part D data.
• CMS will provide up to 3 years of enrollment data for both Part C and Part D.
• Data will be supplied to RREs as part of the NGHP Query Response File.

Query Response File Changes will be the following:

• New query Response file fields become effective 12/11/2021
• Fields 12-13: Most recent Part A effective and termination date
• Fields 14-15: Most recent Part B effective and termination date
• Fields 16-135: Part C data including: Plan Contract Number (PCN), Enrollment Date, Termination Date, Plan Contract Name, Plan Benefit Package (PBP) Number, Plan Contract Address (COB Contact Address), Plan Contract City, Plan Contract State, and Plan Contract Zip Code.
• Fields 136-255 Part D data including: Plan Contract Number (PCN), Enrollment Date, Termination Date, Plan Contract Name, Plan Benefit Package (PBP) Number, Plan Contract Address (COB Contact Address), Plan Contract City, Plan Contract State, and Plan Contract Zip Code.

Things to Remember as noted by CMS were the following:

• Up to 12 instances of each Part C and Part D plan data will be provided.
• If a beneficiary has a MA+PD plan the data will be returned in both the Part C and Part D data fields.
• The full layout of these changes is available in Chapter 5 of the NGHP User Guide on CMS.gov.
• Updated HEW software will be made available.

Section 111 COBSW Beneficiary Lookup Changes (Section 111 Direct Data Entry “DDE” Users):

• Effective October 4, 2021.
• Will have Part C and Part D enrollment information returned when using DDE.
• 3 years of Part C and Part D information up to 12 instances each.
• 500 query limit still applies. 

Testing

• Testing period September 13-December 10^th.
• esting is encouraged but nor required.
• Full testing details will be forthcoming.

Resources to Assist You

• PAID Act Alert
• NGHP User Guide
• 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide
• EDI Department (646) 458-6740

Part C & D Questions

Part C Mailbox: https://dpapportal.lmi.org/DPAPmailbox/

Part D Mailbox: Part D_COB@cms.hhs.gov

Noteworthy Q&A Taken by CMS (questions and answers are paraphrased):

Q: Outside of the Section 111 query process, can we call the BCRC and also receive Part C and D enrollment information?

A: Yes, with proper authorization, Part C and Part D enrollment information can be provided by the BCRC.

Q: What changes will CMS be making to the Part C and D recovery process?

A: There are no changes to the Part C and D conditional payment recovery processes. For questions on the Part C and D conditional payment recovery processes, e-mail the inquiry to the Part C and D mailboxes provided in the presentation.

Q: If the query response file is only providing Part C and D enrollment information going back 3 years, why is CMS providing up to 12 instances of enrollment?

Although most Medicare beneficiaries can only enroll in one plan per calendar year, there are special circumstances in which a beneficiary could change plans mid-year such as special elections, loss of employment, dual eligibility in Medicare/Medicaid, etc.

Q: Will CMS post a copy of this presentation?

A: Yes, we will post it at www.cms.gov within 7-10 days.

Q: Although the PAID Act will change the query process by now providing Part C and D enrollment information in the response file, will this also impact subsequent reporting processes via Section 111?

A: No, the PAID Act will only impact the query process.

Q: Is the Section 111 data also shared with the Part C and D plans?

A: Yes, the Section 111 data is also shared with the Part C and D plans. The Section 111 information provided to Part C and D plans does not contain ORM information or TPOC information, but rather only primary payer information with effective and termination dates.

Q: After finding out about a Part C or D plan, do RREs have an obligation to “chase down” Part C and D plans to determine if there is a conditional payment lien recovery owed?

Questions on the Part C and D recovery processes can be mailed to the Part C and D mailboxes provided in this presentation. The PAID Act simply allows NGHP RREs to become aware of the Part C and D enrollment information.

Q: Does CMS have any plans to take over Part C and Part D conditional payment recoveries?

A: No, recovery of conditional payments is governed by each individual Part C and D plan. Traditional Medicare and the BCRC/CRC have no involvement in the Part C/D conditional payment recovery process; therefore, no changes to the NGHP process at the BCRC/CRC level will occur.

Commentary:

This was an extremely helpful presentation by CMS on the PAID Act. CMS was clear that it encouraged RREs to take advantage of the testing periods so that they are prepared for the expanded Section 111 query response files come December 11, 2021. It was interesting to note that users of Direct Data Entry (DDE) will be able to pull Part C and D enrollment data come October 4^th, a few months prior to release of this future in standard Section 111 query response files in December.

Noteworthy is one question that was asked a few times during the Q&A session: “Once we have the Part C and D information, what are RREs to do with it? Will the Part C and D plans be contacting us if they have a lien, or should we chase them down to see if they have a conditional payment recovery?” CMS noted that the Part C and D plans will have no changes to their processes, and that they currently do receive Section 111 data showing primary plan effective and termination dates. Part C and D plans do not receive ORM or TPOC amounts that RREs report.

Thus, one can conclude that CMS is noting that the PAID Act imposes no affirmative obligation on the part of the NGHP RRE to “chase the Part C/D plan down.” However, with Part C and D plans receiving Section 111 information relative to termination of a claim, which means that the claim has settled/resolved, the Part C and D plan may not reach out to the NGHP RRE for months or potentially years post-settlement. Thus, if the NGHP RRE desires to tie up/resolve any Part C and D conditional payments pre-settlement, it may be wise to reach out to the Part C and D plan to inquire as to any conditional payments to assure no Part C or D conditional payments pop up post-settlement.

Have questions on the PAID Act? Contact me at heather@sandersoncomp.com.

By Heather Schwartz Sanderson

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