PAID Act – current status and FAQsBy Mark Popolizio, Kate Riordan, Jeremy Farquhar | March 10, 2021
A major Medicare secondary payer (MSP) watch-list item for 2021 continues to be how and when CMS will implement 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.
At this time, the industry is waiting for CMS to release its PAID Act implementation plan, which will require yet to be released technical updates to its Section 111 Query Process. Thus, until CMS provides more information, RREs remain in a holding pattern regarding what technical updates may be necessary.
While the industry awaits further information from CMS, 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. As noted above, the industry is waiting for further information from CMS regarding how it plans to implement the PAID Act. Under the PAID Act, CMS has until December 11, 2021, to implement this new law.
Has CMS released any information on how it plans to implement the PAID Act?
Not yet. As referenced above, as of this article’s date, CMS has not released any information regarding how it plans to implement the PAID Act.
How do you anticipate CMS will release information on its PAID Act implementation plans?
In the coming months, it is expected CMS will update its Section 111 NGHP User Guide to provide RREs with information and direction regarding the additional eligibility/enrollment information, which it will return via its Query Response files as required under the PAID Act. By way of general information, Chapter V of CMS’s NGHP Section 111 User Guide contains the current Query Input and Query Response flat file layouts for those RREs making use of CMS’s free HEW Translator software to perform their EDI X12 conversions. It is expected CMS’s upcoming changes should only apply to the Query Response file layouts. Since the PAID Act does not require RREs to submit any additional information to CMS, no changes are expected to the Query Input File.
As part of updating the NGHP Section 111 User Guide, it is also anticipated that CMS will release revisions to its 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide. CMS provides this Companion Guide for those RREs who utilize their own EDI X12 translator software as opposed to the free HEW software offered by CMS. It is intended for use alongside the National Electronic Data Interchange Transaction Set Implementation Guide and the Health Care Eligibility Benefit Inquiry and Response, ASC X12N 270/271 (005010X279A1) Implementation Guide. Changes to CMS’s Companion Guide are anticipated to provide mapping for the additional eligibility/enrollment data elements that CMS will soon return within their X12 271 Query Response Files. Updates to both these guides will give RREs technical direction to ensure accurate processing of the additional query response file data fields provided for by the PAID Act.
Is there anything RREs should be doing regarding their Section 111 systems as we wait for CMS’s next move?
At present, and until CMS publishes their updated file specifications, there is little RREs can do to prepare from a technical standpoint. That said, as more fully discussed in #5 above, it is expected that CMS will publish updated technical specifications in the coming months. While it is unknown when CMS will release its implementation plan, it is expected the agency will allow some time for the industry to assimilate the changes before implementation goes live.
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 whatever technical changes are necessary for our ClaimSearch CMS and MSP Navigator customers once we have more information and direction from CMS. Rest assured our reporting solutions will be ready to accommodate and assimilate the changes CMS makes to the Section 111 Query Process.
Will ISO Claims Partners provide updates once CMS starts to release its implementation plans?
Yes. We will be releasing new articles and updated client alerts once CMS starts to release its implementation plans. Also, we will hold updated webinars as future developments may warrant. You can listen to our January 11, 2021, webinar here. We are always available to set-up private discussion calls or webinar training as well.
Outside of the Section 111 updates, how can we take advantage of the information the PAID Act will provide?
As more fully noted in #1 above, the PAID Act requires CMS, as may be applicable, to provide RREs with the names and addresses of a claimant’s Medicare Part C (Medicare Advantage) and/or Medicare Part D (prescription drug) plans. 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.
10. If I want to discuss the PAID Act or set up a webinar, what do I do?
 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 6.2, January 11, 2021).
 See n. 1 above.
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