Medicare C/D Casework Processes for Resolution

1. Medicare C/D Casework Processes for Resolution Maureen Kerrigan

2. Topics Covered • Resolving C/D Cases • Medicare Marketing and Communications Guidelines • New C/D Policies • Tools

3. Primary Responsibility Is with Plans Part C - Medicare Advantage (MA), Cost, PACE, Demonstrations and Part D- Prescription Drug Plan Organizations Are required to manage complaints received on behalf of beneficiaries

4. Complaint Tracking Module Health Plan Management System (HPMS) Complaint Tracking Module (CTM) encompasses the entry, tracking, review, assignment and follow-up of beneficiary and provider complaints.

5. SHIP Use of CTM • CTM allows SHIP users to directly enter complaints for routing to CMS and/or plans real-time, promptly initiating complaint resolution process • SHIP users can also use to evaluate whether complainants are receiving satisfactory information and timely resolution of their issues • Step-by-step instructions on how to view, search, add and print complaints, view casework and add comments in CTM User Manual for SHIP • Guidance on appropriate CTM entry in SHIP CTM SOP

6. SHIP Use of CTM • Access granted solely on “need to have” basis • SHIP Directors should independently assess if system access necessary and efficient to best support their activities • Access is not to be requested for SHIP volunteers • Every Regional Office has a CTM Point of Contact (POC) for SHIPs • Different function than Regional Office SHIP Liaison

7. Personally Identifiable Information (PII)/Personal Health information(PHI) PII and PHI should not be sent via e-mail • Phone or fax instead • PII is any data that could potentially identify a specific individual • Example: Derf vs John Smith in NYC • Adding last name, city/town, state • PHI is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual.

8. Types of Complaints

9. Good Cause Reinstatements for Failure to Pay Premiums • Plan Issue: CMS does not review/evaluate • Unless qualify for a Special Enrollment Period need to wait until the next Annual Enrollment Period (AEP) • If unusual and unforeseen event, such as a prolonged hospitalization, plans consider reinstatement requests if: • been less than 60 days since disenrolled, and • they can pay owed payments. Financial hardship is not considered an unusual and unforeseen event

10. CTM Good Cause Entry CTM entry only when: • the beneficiary has had difficulty receiving a good cause determination from their plan, • the beneficiary has not received a denial of good cause reinstatement

11. Part D Income Related Monthly Adjustment Amount (IRMAA) • SSA Issue • If beneficiary disagrees that they have to pay IRMAA or disagree with the IRMAA amount • If due to unforeseen and extenuating circumstances, a beneficiary was disenrolled for failure to pay Part D IRMAA, they can be evaluated for Good Cause

12. Potential Fraud, Waste and Abuse • FWA complaints should be referred to the Medicare Drug Integrity Contractor (MEDIC) 1-877-7SAFERX • A complaint can also be entered in the CTM

13. Enrollment/Disenrollment • Beneficiary lost Medicare entitlement and needs it restored to regain access to MA or Part D coverage/access • Need update to beneficiary’s record, eg "erroneous death" reported

14. Enrollment Exceptions • Enroll/change plans outside available enrollment period • Unable to enroll/disenroll from a plan due to exceptional circumstances (e.g. prolonged hospitalization). • Seeks to change plans due to a significant provider network change that impairs ability to successfully acquire needed services. • Used infrequently as networks change regularly

15. Medicare Marketing and Communications Guidelines

16. Marketing Allegations • In CTM, “Plan Lead” under Marketing • “CMS Lead” complaint if the beneficiary seeks disenrollment from the plan due to the alleged misrepresentation • Marketing complaints are shared with state Departments of Insurance, who oversee agents/brokers in their state

17. Marketing vs Communication Marketing • Intent –to draw a prospective or current enrollee’s attention to plan to influence decision when selecting and enrolling in a plan or deciding to stay in a plan (retention-based marketing). • AND Content –type of information that would be intended to draw attention to a plan or influence beneficiary’s enrollment decision, eg information about benefits or benefit structure Communications

18. Advertised as educational Hosted in public venue by plan or an outside entity Can include communication activities and distribution of communication materials Beneficiary-initiated questions can be answered Educational Events

19. Plans must submit scripts and presentations to CMS prior to use (including ones used by agents/brokers) Sign-in sheets must be clearly labeled as optional Health screenings or other activities that may be perceived as, or used for, “cherry picking” May not require attendees to provide contact info as a prerequisite for attending event Cannot use contact information for potential enrollees for anything besides raffles or drawings Marketing events

20. Scope of Appointment • Required for all one on one appointments, regardless of venue • Discussions only about previously agreed- upon plan products documented in the SOA • May only market health-related products

21. Acceptable Phone Activities • Call current enrollees • Call beneficiaries who submit enrollment applications to conduct enrollment business • Call former enrollees after disenrollment effective date for quality improvement disenrollment surveys • With CMS approval, call LIS-eligible enrollees to encourage them to remain enrolled in current plan. • Call individuals who have given permission • Return phone calls or messages

22. Non-Acceptable Telephonic Contact • Unsolicited calls about other business as a means of generating leads for Medicare plans • Calls based on referrals • Calls to market plan or products to former enrollees who have dis-enrolled or to current enrollees who are in the process of voluntarily dis-enrolling

23. Non-Acceptable Telephonic Contact • Calls to beneficiaries who attended a sales event, unless the beneficiary gave express permission at the event for a follow-up call (must be documentation of permission to be contacted) • Calls to prospective enrollees to confirm receipt of mailed information

24. Plan may initiate contact vial email to prospective enrollees and to retain current enrollees. Must include opt-out process on each communication to elect to no longer receive emails. Electronic communication

25. Plans may send conventional mail and other print media (advertisements, direct mail) to potential enrollees Plans may not: Use door-to-door solicitation, including leaving information (such as a flyer) at a residence Approach potential enrollees in common areas (parking lots, hallways etc.) Use telephonic solicitation, including leaving electronic voicemail messages unsolicited contacts

26. Be worth no more than $15 or $75 total per person, per year Be offered to all regardless of enrollment Not be items considered a health benefit May not provide or subsidize meals but may provide refreshments and light snacks Promotional Materials

27. NEW C/D Policies: MA OEP LIS SEP “At Risk” Beneficiaries

28. NEW: Medicare Advantage (MA) Open Enrollment Period (OEP) • MA OEP started in 2019 • January 1 – March 31 each year • Must be in MA Plan on January 1 to use MA OEP • Can only use once • New Medicare beneficiaries who enroll in MA during their initial enrollment period • MA OEP during first 3 months

29. What You Can Do During MA Open Enrollment Period • Switch MA Plans • Leave MA to join Original Medicare • Coordinating Part D SEP • MA Plan cancelled when you enroll in another MA or a PDP • Can add or drop Part D when switching plans

30. What You Can’t Do in MA OEP • Switch more than once • Switch from 1 prescription drug plan to another standalone PDP • Switch from Original Medicare to join a MA plan. • Not available for those enrolled in other Medicare health plan types (such as cost plans or PACE). • Replaces MA Disenrollment Period, which ended 2018

31. NEW: Changes in Duals/Low-Income Subsidy (LIS) SEP Can only change plans one time per calendar quarter in first 3 quarters • Annual Open Enrollment Period (OEP) can be used in the 4th quarter Have new 3-month SEP following: • A gain, loss, or change to Medicaid or LIS status • Notification of a CMS or State-initiated enrollment action

32. NEW: At Risk Duals/Low-Income Subsidy (LIS) SEP Limitations Individuals who have been notified that they’re “potentially at risk” or “at-risk” under a drug management program cannot use the dual/LIS SEP • Limitation lasts until “at-risk” determination expires or terminated by plan • At-risk status can be appealed to plan • Decision based on opioid use, dosage, and number of providers used

33. At Risk Duals • Other election periods are still available – AEP, other SEPs

34. Tools

35. Eligibility and Enrollment Guidancehttps://www.cms.gov/Medicare/Medicare.html CMS issues guidance to outline who’s eligible to enroll in Medicare plans, when and how they’re able to enroll and disenroll, and more.

36. National Training Program • Webinars • Workshops • Self-paced online trainings • Job aids, eg Drug Coverage Under A, B, and D • Tools – eg how to use Plan Finder

38. CMS Manuals https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html The manuals offer day-to-day operating instructions, policies, and procedures. Select the IOM link to access CMS manuals

39. Internet-Only Manuals (IOMs) CMS has 25 Internet-Only Manuals covering a variety of topics Let’s say you want to know if Medicare will pay for a private hospital room

40. Internet-Only Manuals (IOMs) (continued) Each manual is broken up into chapters, according to topic

41. 1-800-MEDICARE (1-800-633-4227) Help from a customer service representative • General Medicare questions • Specific billing questions and questions about claims, medical records, or expenses  • Recordings of frequently asked questions • Ordering publications • Available 24 hours a day, including weekends • TTY users can call 1-877-486-2048

42. Unique IDs • SHIP and SMP counselors with active Unique IDs through the ACL SHIP Tracking and Reporting System (STARS) and the SMP Information and Reporting System (SIRS) databases are eligible to use the SHIP/SMP number. • When a counselor calls 1-888-647-6701, an automated voice will prompt the counselor to enter his or her SHIP or SMP Unique ID. And receives a very brief list of options

43. Unique IDs For efficiency the menu is not as long and descriptive as the menus for accessing customer service representatives through the 1-800-MEDICARE number • Press 1 If you have General Medicare questions (these include Part D questions or calls to enroll in a plan) • Press 2 If you have questions about a doctor’s service or hospital visit • Press 3 If you have a question about medical supplies • This number will not bypass or put a SHIP or SMP counselor in any kind of priority

44. Medicare.gov • Publications • Information in Other Languages • Medicare Forms • Mail from Medicare • Guide to Consumer Mailings from the Centers for Medicare & Medicaid Services (CMS), Social Security and Plans • Medicare Plan Finder

45. Mymedicare.gov • Check health and prescription drug enrollment information. • Manage prescription drug list and other personal health information • Check claims • Find eligibility, entitlement, and preventive service information. • View Part B deductible information.. • Create an “On the Go Report” that allows you to print your health information to share with healthcare providers.

46. Mail You Get About Medicare https://www.medicare.gov/forms-help-resources/mail-you-get-about-medicare Mail People who have Part D & Extra Help Get • Notice of Creditable Coverage • Explanation of Benefits (EOB) • LIS Choosers Notice Mail People with Other Medicare Health Plans Get • Plan Annual Notice of Change (ANOC) • Evidence of Coverage (EOC) • Plan Non-Renewal Notice

47. Guide to Consumer Mailings from CMS, Social Security & plans Guide to Consumer Mailings from CMS, Social Security & plans

48. Cms.gov • Eligibility and Enrollment Guidance • Medicare Coverage Database • Regulations and Guidance • CMS Manuals • Internet-Only Manuals • Research, Statistics, Data and Systems

49. productordering.cms.hhs.gov Returning User: • Enter your username and password in the designated fields, and then select the “Sign In” button. New User: • Select the “Request an Account” button to set up a new account. • Enter the required information, then follow the prompts for setting up a new account, and select the “Request Account” button. productordering.cms.hhs.gov Questions? Email your questions to: support@cmspow.us

50. SEP—Full or Partial Duals to Use Once Per Calendar Quarter During First Nine Months