On June 23rd, the Centers for Medicare and Medicaid Services (CMS) held a webinar to discuss its plans to implement the Provide Accurate Information Directly Act (PAID Act) for non-group health plan (NGHP) responsible reporting entities (RREs).
The PAID Act, in general, requires CMS to expand its Section 111 Query Process to provide NGHP RREs with certain information regarding a claimant’s enrollment in a Medicare Part C (Medicare Advantage) plan and/or a Medicare Part D (prescription drug) plan.
Prior to this webinar, CMS released an updated Section 111 NGHP User Guide, Version 6.4 (June 11, 2021) which outlined, in part, the agency’s implementation plans. As part of this webinar, CMS took the opportunity to reiterate the information released in the new User Guide and provide anticipated timelines for testing and implementation. Importantly, CMS indicated that RREs must be ready to receive the additional information that will be provided per the PAID Act as part of their reporting systems as of December 11, 2021 – the PAID Act’s go-live date. Also, CMS will be opening a voluntary RRE testing period starting September 13th.
To help put CMS’s webinar in context, in this article the authors first set the stage with a brief review of CMS’s PAID Act implementation plans as outlined in the recent User Guide updates. This is then followed by a general summary of the key points discussed by CMS on this webinar. The final part of this article provides links to our new PAID Act “nutshell summary” and upcoming PAID Act update webinar.
PAID Act implementation – CMS Section 111 NGHP User Guide, Version 6.4
As mentioned, prior to the webinar CMS released its PAID Act implementation plans as part of recent NGHP Section 111 User Guide updates.
In the new User Guide, CMS notes, in part, that it will be updating the Query Response file and HIPAA Eligibility Wrapper Software (HEW) as follows:
Query Response File – The Query Response File will be updated to include: Plan Contract Number (PCN), Contract Name, Plan Benefit Package (PBP) Number, Coordination of Benefits (COB) Address, and Entitlement Dates for the last three years (up to 12 instances) of Part C and Part D coverage. The updates will also include the most recent Part A and Part B entitlement dates.
HEW wrapper software -- The HEW software will also be modified to extract the additional fields from the response file. Finally, process steps for installing and configuring the HEW software will be provided (see chapter V, HEW Query Response File Record and HEW Query Response File Record – Version 4.0.0 and Appendix K). CMS plans to release Version 5.0.0 of the HEW Software on September 13, 2021 and RREs will be able to utilize the new version of the translator software for testing purposes between September 13, 2021 and December 10, 2021.
Regarding file formatting, CMS notes that the data elements being returned within the pre-existing response file format will remain populated within the same data positions while the new data elements will be appended to the end of the record layout.
Summary of CMS webinar discussion points
Turning to CMS’s webinar, overall CMS’s presentation and discussion mostly reiterated the information provided in the updated NGHP User Guide outlined in the preceding section. CMS spent a significant portion of the webinar addressing questions from the audience.
The following are key summary points discussed by CMS on the webinar:
- Query File Response File changes and related information – RREs must be prepared to receive the additional information CMS will be providing as part of their reporting systems as of December 11, 2021
CMS confirmed that as of December 11, 2021, RREs will need to be able to absorb the new, expanded Query Response file via the HEW application as the old version will be discontinued. For those reporters using their own EDI translator software, as opposed to CMS’s free HEW application, they will need to be prepared to ingest the updated X12 271 response file format for which specifications have been provided via CMS’s updated NGHP Companion Guide. CMS also noted that, at present, there are no plans to restrict the number of queries RREs may submit and the current 14-day turn-around time from query submission to response is expected to remain following implementation.
In addition, CMS indicated that in situations where a beneficiary is enrolled in what they referred to as a “MAPD plan” (a Medicare Advantage plan which includes both Part C and D coverage via the same policy), RREs will see the same plan enrollment information duplicated within both the Part C and Part D specific fields within the query response. Further, CMS advised that if a beneficiary indicates the Plan data is incorrect the beneficiary will need to update their information by contacting Medicare directly. CMS also reiterated that the PAID Act has no impact on current Section 111 reporting obligations and requirements.
- Key implementation dates and timelines
CMS noted the following important dates and timelines regarding PAID Act implementation:
September 9th – CMS webinar on general testing matters
CMS plans to hold a webinar on September 9th prior to the launch of testing and the other activities noted above. This webinar will focus on general testing matters, including the testing of new software. Also, it is expected that CMS will provide additional information regarding testing on this webinar. CMS has not yet released the official notice with the call-in formation, etc. for this event. Once this information is provided, we will update this article and issue a new article alert.
September 13th to December 10th - RRE testing period, related activity, and new HEW software
CMS will open up a testing period from September 13, 2021 through December 10, 2021.
While testing is not mandatory, CMS encouraged RREs to take advantage of this opportunity. As part of testing and overall implementation, CMS noted that a HEW Application update will be available for download on September 13th. CMS indicated that this new HEW software has been designed in order that it can be installed in parallel with the prior version in order to allow RREs to test using the new version at the same time they continue to use the prior version for their production submissions through December 10th.
October 4th – Updates to the S.111 COBSW Beneficiary lookup tool
On October 4th, CMS plans to update the S. 111 COBSW Beneficiary lookup tool to include Part C and Part D data for RREs using direct data entry (DDE) enabling these entities to access Part C and Part D enrollment data as well. CMS noted that the five-hundred query limit will still applies in these instances.
December 11, 2021 – PAID Act goes live
As referenced above, CMS’s PAID Act implementation plans become effective on December 11, 2021 and all RREs must be ready to receive the additional information that will be provided per the PAID Act as part of their reporting systems.
- Medicare Advantage and Part D recovery
Regarding Medicare Advantage and Part D recovery activities, CMS underscored that no new data would be transferred to these plans as part of the PAID Act and any inquiries regarding Medicare Advantage or Part D recovery processes should be addressed to the following mailboxes: Part C Mailbox: https://dpapportal.lmi.org/DPAPMailbox/ and Part D Mailbox: PartD_COB@cms.hhs.gov.
- CMS’s PAID Act resources
CMS also advised the audience of various CMS PAID Act implementation resources and related information, including its recent Technical Alert, NGHP User Guide, and 270/271 Health Care eligibility Benefit Inquiry and Response Companion Guide. Please see our recent article regarding these items.
Of note, CMS plans to release the presentation used as part of this webinar in the near future. We will update this article to include a link to CMS’s presentation once it is released.
NEW – PAID Act Nutshell Summary
As an additional resource, please see our new PAID Act nutshell summary which provides a general and non-exhaustive overview of the PAID Act and CMS’s implementation plans.
Sign up for our PAID Act webinar!
Join us on July 12th for our Get Ready for the PAID Act: CMS Updates, Claims Considerations, and Next Steps webinar where we will discuss all the latest developments, how they impact insurers, and other compliance considerations. Register now!
Of course, please do not hesitate to contact the authors if you have any questions or would like to set up a PAID Act discussion call. Finally, please note that ISO Claims Partners will be incorporating any applicable technical reporting changes necessitated by CMS’s updates into its various reporting platforms.
 In pertinent part, the text of the PAID Act reads as follows:
(ii) SPECIFIED INFORMATION.— In responding to any query made on or after the date that is 1 year after the date of the enactment of this clause from an applicable plan related to a determination described in subparagraph (A)(i), the Secretary, notwithstanding any other provision of law, shall provide to such applicable plan—
(I) whether a claimant subject to the query is, or during the preceding 3-year period has been, entitled to benefits under the program under this title on any basis; and
(II) to the extent applicable, the plan name and address of any Medicare Advantage plan under part C and any prescription drug plan under part D in which the claimant is enrolled or has been enrolled during such period.”
H.R. 8900, Further Continuing Appropriations Act, 2021, and Other Extensions Act, Title III, Offsets, Sec. 1301, (ii), Transparency of Medicare Secondary Payer Reporting Information.
 CMS noted in its recent User Guide updates that its PAID Act implementation plans will become effective as of December 11, 2021. See, CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.
 CMS’s Section 111 NGHP User Guide, Chapter IV (Version 6.4, June 11, 2021), Chapter 1, p. 1-1.
 See, CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.4, June 11, 2021), Chapter V, Appendix E, pages E-6 to E-30.
In reviewing the noted information that CMS plans as part of the Query Response file, it is interesting to note that CMS plans to provide more information than is technically required per the text of the PAID Act. On this point, the PAID Act only requires that CMS provide “the plan name and address” of any identified Medicare Advantage or Part D plan. However, as noted, CMS also plans to provide the contract number, contract name, plan number, and the plan’s COB address. See n. 1. Having this additional information may prove helpful in terms of following up with the identified plan(s) to obtain and address any recovery claims. In addition, it is interesting to note that CMS is also planning to include the most recent Part A and Part B effective and termination dates. Historically, Part A and B coverage dates have never been provided for NGHP entities and their inclusion should provide even greater clarity in terms of overlapping coverage and aid further in terms of appropriate coordination of benefits. From another angle, it is noted that CMS will be limiting the number of distinct Part C and D coverage periods being returned to “12 instances.” This is likely due, in part, to file size restrictions coupled with the unlikely occurrence of a Medicare beneficiary having more than 12 different coverage enrollment periods over the three-year time span identified per the PAID Act.
 See, n. 2 above.