Part D-IRMAA Disenrollments & Good Cause

Part D-IRMAA Disenrollments &
Good Cause Reinstatements
An Update of Process and Interactive QA Session
Patty Helphenstine & Roslyn Thomas, CMS
April 11, 2012
Part D-IRMAA Disenrollments
• Part D-IRMAA – extra amount in addition to premium
• Most have IRMAA collected via premium withhold via
• RRB direct billing; CMS direct billing for those without
premium withhold via SSA/OPM
• Direct Billing by CMS
• Monthly billing; always due on 25th of month prior to coverage
• E.g.: Bill for May coverage due April 25
• 3 month grace period for non-payment
• 3 billing months PLUS ~15 days before disenrollment TRRs generated
• Maintain coverage through end of month
Part D-IRMAA Disenrollments
• Disenrollments started 4/1/12
• First TRRs sent on 3/9 for 3/31/12 disenrollment date
• Disenrollment effective date is 4/1/12 (1st date w/o coverage)
• Disenrollments processed monthly
• Our system processes disenrollment code around 7-10th
of the month
• Expect TRR (TRC 293) around that date
• Plan sends notice of disenrollment within 10 calendar days
• Last day of coverage is the end of that month
Part D-IRMAA Disenrollments
• TRR Issue
• Alert from MAPD Helpdesk sent on 3/23/12
• TRR should include dates in Fields 18 & 24 – only Field 18
• Field 18 – 1st date individual is no longer enrolled (always 1st of month)
• Field 24 – last day of individual’s enrollment (always last day of month)
• Plans use Field 18 to disenroll in their internal systems
• Last date of coverage should be 1 day prior to date in Field 18
• Plan Process
• Process as involuntary disenrollment; have model
• Once receive TRC, disenrollment is final – please no
additional outreach to affected individuals
Part D-IRMAA Reinstatements
• CMS will effectuate reinstatements for Part D-IRMAA
disenrollment error
• Wrong individual disenrolled
• Individual made full payment of all owed amounts timely
• Individual to call 1-800-MEDICARE and indicate possible error
• Verify disenrollment is TRC 293 (failure to pay Part D-IRMAA)
• Handled using separate process than Good Cause
• If error, CMS will reinstate individual
• Plan Process
• TRR will indicate reinstatement
• Plan notify individual of access to services
Good Cause
• Review of Good Cause Basics
• Individual requests Good Cause reinstatement via
• Plan receives request – please refer to 800#
• Individual must request reinstatement within 60 calendar days
of disenrollment effective date (Day 1 = 1st of month w/o
• If receive favorable determination from CMS, individual must
pay all owed amounts (past due + 3 months of premiums)
within 3 months of disenrollment prior to reinstatement
• If unfavorable and no indication of error, individual remains
disenrolled and can make a new enrollment request to any
plan at next available election period (AEP, SEP, etc)
Good Cause
• CMS Process – Triage occurs prior to CTM generation
• Verify disenrollment TRC (plan premiums or Part D-IRMAA)
• Allegations of error utilize separate process, not continued in
Good Cause process
• Verify disenrollment date within 60 calendar days
• Receive positive attestation on ability to pay all past due
amounts + 3 months of premiums within 3 months of
• Receive positive attestation of unexpected and uncontrollable
circumstance occurring 2-3 months prior to disenrollment
• If all steps are affirmed, CTM is generated with details about
individual’s circumstance and routed to CMS caseworker
Good Cause
• Early implementation identified some lessons learned
• CTM categorization and timeliness flags
• Plan involvement in review of cases
• Coaching of individuals
• Improved phone scripts, triage and processing
• Good Cause CTMs from 800# initially routed to CMS ROs,
not plans
• Only marked “Urgent” when favorable CTM sent to plan for action to
notify individual of amount owed within 3 business days and to
collect payment
REMEMBER: CTM will remain open until payment received or 3 months
after disenrollment. NOT counted in timeliness reports or plan
performance metrics
Good Cause
• Improved 800# scripts, triage and processing
• Established separate process for allegations of plan error
• If individual alleges plan error with 800# or while providing details of
circumstance, CTM goes to plan to address/resolve as plan error
• If CMS Caseworker obtains additional information from individual
alleging plan error after Good Cause CTM was generated, they will
reassign the CTM to the plan to resolve possible error
• CTM summary may have details of other circumstances that sound like
Good Cause – still determine if plan error
• Special process for indication of possible Good Cause request
during determination of plan error
• Plan may reassign CTM to CMS for action as Good Cause IF:
- Plan receives CTM for plan error and finds none, AND
- Individual makes indication they had good reason for not paying timely
• CMS RO will triage and handle as Good Cause request
Good Cause
• Plan involvement in Good Cause cases is only once
favorable determination is made
• Please do not coach individuals with forming the accounts of
their circumstances
• Other notable items:
• Plans may not permit partial payment for Good Cause
reinstatements – MUST pay all past due + 3 months
• Plans may contact individual to remind of payment due date or
take payment via phone (EFT, credit card)
Good Cause
• Other notable items:
• Plans may provide access to services upon receipt of full
payment (if no Part D-IRMAA)
• Part D-IRMAA cases – MUST wait to provide access to services until
receive TRR or approval from CMS caseworker
• Plans need to update CTM and send to CMS for action so reinstatement
can be processed (expectation – within 5 days of receipt of full payment)
• Plans have option to wait extra days to assure payment clears
bank before updating CTM
• Business decision by the plan, not requirement
• If subsequently find payment did not clear, work with your Account
Manager/Lead Caseworker to remove reinstatement
• HPMS memo (1/5/12) provided 5 extra days for plans to
process and update individual’s account for payments
received near or on the last day of the third month.
• Guidance Documents:
• Publication on IRMAA:
• HPMS Memorandums and Notifications:
• 5/27/2011 – Part D-Income Related Monthly Adjustment Amount Updates
• 12/8/2011 – Disenrollment for Failure to Pay Part D-Income Related Monthly
Adjustment Amount
• 3/23/2012 – MAPD Helpdesk Alert on Part D-IRMAA Disenrollment
• 9/30/2011 – Updated Complaints tracking Modules (CTM) Guidance on
Standard Operating Procedures (SOP)
• 1/5/2012 – Reinstatement Based on “Good Cause” Determinations for
Failure to Pay Plan Premiums or the Part D-IRMAA
Part D-IRMAA and Good Cause

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