UPDATED July 16, 2021
A major Medicare secondary payer (MSP) watch-list item for 2021 is CMS’s eventual implementation of the Provide Accurate Information Directly (PAID) Act. Signed into law on December 11, 2020, the PAID Act will make changes to CMS’s Section 111 Query Process. In general, under the PAID Act, CMS will be required to provide RREs with information regarding a claimant’s Medicare Part C (Medicare Advantage) and Medicare Part D (prescription drug) enrollment status through the Section 111 Query Process.
CMS recently released its PAID Act implementation plans, and this new law is now a step closer to going live. In this article, the authors provide the following PAID Act overview in “question/answer” format, which RREs may find helpful:
- What does the PAID Act do?
The PAID Act requires CMS to expand the Section 111 Query Process to (i) identify whether a claimant subject to the query is, or during the preceding 3-year period has been, entitled to benefits under the Medicare program; and if so, (ii) CMS must provide the RRE with 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.
To put this into perspective, currently, when an RRE submits the required Query Process data elements to CMS, if the queried individual is identified as a Medicare beneficiary, the Query response only confirms he/she is enrolled in Medicare. It does not provide any information about which “part” of the Medicare program he/she is enrolled in.
The PAID Act will change this. Under the PAID Act, if the individual is identified as a Medicare beneficiary and is currently entitled to, or during the preceding three-year (3) period has been entitled to, Medicare Advantage and/or Part D benefits, CMS will now have to provide the RRE with the names and addresses of any such Medicare plan through the Section 111 Query Process. Accordingly, RREs will now be able to identify better whether a claimant is a Medicare Advantage and/or Part D plan enrollee.
- Does the PAID Act require RREs to provide any new information or data points to CMS as part of the Section 111 process?
No. As more fully noted in #1 above, the PAID Act requires CMS to expand its Query Process and provide RREs with information regarding a claimant’s Medicare Part C (Medicare Advantage) and/or Medicare Part D (prescription drug) enrollment status. The new law does not require RREs to provide CMS with any new information or data.
- Is the PAID Act “live” at this time?
No. Per CMS’s Section 111 NGHP User Guide (Version 6.4, June 11, 2021), PAID Act implementation is scheduled to become effective on December 11, 2021.
- Has CMS released any information on how it plans to implement the PAID Act?
Yes. CMS has released its PAID Act implementation plans as part of recent updates to its Section 111 NGHP User Guide (Version 6.4, June 11, 2021).CMS held a PAID Act webinar on June 23rd where it outlined its implementation in more detail. See CMS's PowerPoint presentation here and our CMS PAID Act webinar article for more information.
- How does CMS plan to implement the PAID Act?
To help implement the PAID Act, CMS notes 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: Contract Number, Contract Name, Plan 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.
In reviewing CMS’s information above, a few observations surface. For example, it is noted that CMS plans to provide more information than is technically required under the PAID Act. Specifically, 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. 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.
Also, 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 a three-year time span.
In terms of file formatting, it is noted that 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 simply be added on to the tail end of the record layout.
6. Will ISO and ISO Claims Partners be ready to implement CMS’s updates to the Query Process as part of the PAID Act?
Yes. Our teams are ready to make the necessary technical changes to our ClaimSearch CMS and MSP Navigator reporting platforms. Rest assured our reporting solutions will be ready to accommodate and assimilate the changes CMS makes to the Section 111 Query Process.
7. Has ISO Claims Partners released any other resources on the PAID Act?
Yes. In addition to this article, please consult our companion PAID Act resources: New NGHP Section 111 User Guide (6.4) – PAID Act, ORM termination, and other updates and CMS releases its PAID Act implementation plans – what’s next and how we can help
8. Outside of the Section 111 updates, how can insurers take advantage of the information the PAID Act will provide?
As more fully noted in #5 above, CMS will be providing RREs with key information regarding a claimant’s Medicare Advantage and Part D enrollment. With this information, RREs will now be in a better position to contact the plans to obtain and address Medicare Advantage and Part D recovery information. Access to this expanded information could play a vital role in proactively addressing increasing Medicare Advantage and Part D recovery claims. In this regard, over the past few years (and continuing), there have been several decisions from around the country where courts have allowed Medicare Advantage Plans to sue insurers for “double damages” – and in some instances, double damages have been levied against insurers. View our State-by-State Guide to Medicare Advantage in the Courts here.
Thus, insurers may wish to consider taking advantage of the information the PAID Act will provide to establish protocols to make sure Medicare Advantage and Part D recovery claims are addressed --- and we can help you here! In addition to updating our Section 111 reporting systems, we are expanding our conditional payment services to help insurers address MAP and Part D recovery claims based on the information the PAID Act will provide – including an optional add-on feature to our popular programmatic CP Link service. Learn more about our CP Link and Medicare Advantage resolution service here.
9. If I want to discuss the PAID Act or set up a webinar, what do I do?
Contact Mark Popolizio at firstname.lastname@example.org or Kate Riordan email@example.com if you have any questions or would like to set up a call or webinar session on the PAID Act.
 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.
 In general, as part of CMS’s Section 111 Query Process, the data elements that Responsible Reporting Entities are required to submit include a Medicare ID or SSN or last 5 digits of the SSN; first initial of the first name; the first six characters of the last name; date of birth; and gender (M/F). See CMS’s NGHP User Guide, Chapter IV, Technical Information, Chapter 8- Query Files, (Version 6.4, June 11, 2021).
 See n. 1 above.
 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.
 CMS’s Section 111 NGHP User Guide, Chapter V (Version 6.4, June 11, 2021), Chapter V, Appendix K, p. K-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.