July 2014 Retiree Drug Subsidy (RDS) Community Information Group (CIG) Webinar: Preparing for the Medicare Part D Open Enrollment Period

The Retiree Drug Subsidy (RDS) Community Information Group (CIG) hosted a webinar on Wednesday, July 23, 2014 to assist the Plan Sponsor community in preparing for the 2015 Medicare Part D Open Enrollment Period (OEP), which occurs from October 15 – December 7, 2014. Over 275 individuals attended the webinar allowing them to stream audio and view presentation slides.

The webinar was presented by Lisa Hesseltine, a subject matter expert for the Education, Training, and Outreach division of CMS' RDS Center. The webinar covered the following topics:

Review these topics for a summary of the information presented, as well as links to recommended resources.

Webinar Topics:

Impact of the Medicare Part D Open Enrollment Period on Qualifying Covered Retirees

The Medicare Part D Open Enrollment Period (OEP) can have a significant impact on a Plan Sponsor's ability to receive subsidy for a Qualifying Covered Retiree (QCR).

Participants were shown a timeline diagram that described how OEP can affect receiving subsidy for a QCR. The majority of 2015 RDS applications are calendar year plans with a January 1, 2015 start date. The Application Deadline for these applications is October 2, 2014; the deadline with a 30-day extension is November 3, 2014. Therefore, for applications with a November 3 extended Application Deadline, a portion of the OEP falls before the deadline, allowing a beneficiary to enroll in Medicare Part D prior to being established as an RDS QCR. If a beneficiary is enrolled in Medicare Part D, Plan Sponsors cannot receive subsidy for the period enrolled.

Ms. Hesseltine reminded participants that a QCR is established when:

  • Both the Valid Initial Retiree List and the application are submitted prior to the Application Deadline.
  • The Valid Initial Retiree List has a status of "Verified" on the RDS Secure Website (SWS).

OEP Scenarios

Ms. Hesseltine discussed three different OEP scenarios for when a beneficiary attempts to enroll in Medicare Part D during the RDS Application Submission Process:

Scenario 1: Your beneficiary attempts to enroll in Medicare Part D after you submitted the Valid Initial Retiree List and the application. The Valid Initial Retiree List was verified before the start of OEP.

This is the best case scenario. The beneficiary is approved as an RDS QCR before attempting to enroll in Part D, so the Medicare Beneficiary Database (MBD) flags the beneficiary as an RDS QCR and sends a Part D Rejection Notification to the RDS SWS. The Plan Sponsor receives Reason Code 20 (Beneficiary attempted to enroll in Medicare Part D and received an initial rejection) in a Weekly Notification File and has an opportunity to contact the beneficiary before he/she attempts to enroll in Part D again.

Scenario 2: Your beneficiary attempts to enroll in Medicare Part D after you submitted the application but before you submitted the Valid Initial Retiree List.

In this scenario, the beneficiary successfully enrolls in Part D. Because the Valid Initial Retiree List has not yet been processed, MBD is not yet aware of the Plan Sponsor's intent to establish the beneficiary as an RDS QCR. When the Valid Initial Retiree List processes, the beneficiary is rejected for RDS subsidy. The Plan Sponsor receives Reason Code 10 (Enrolled in Medicare Part D) in the Response File.

Scenario 3: Your beneficiary attempts to enroll in Medicare Part D after you submitted the Valid Initial Retiree List (VIRL) but before you submitted the application.

Since the application is not yet submitted, the Valid Initial Retiree List is not verified. When the beneficiary enrolls in Part D, MBD is not yet aware of the Plan Sponsor's intent to establish the beneficiary as an RDS QCR. Therefore, when the Valid Initial Retiree List processes, the beneficiary is rejected for RDS subsidy. The Plan Sponsor receives Reason Code 10 (Enrolled in Medicare Part D) in the Response File.

Tips on How to Avoid Scenarios 2 and 3

Three things Plan Sponsors can do to avoid Scenarios 2 and 3 are:

  1. Send the Creditable Coverage Notice to beneficiaries, educate them about prescription drug benefits and RDS, and educate them about what not to do during OEP.
  2. Establish QCRs early (before OEP, if possible).
  3. Monitor and manage QCRs by regularly processing RDS Response Files and Notification Files and requesting and downloading the Covered Retiree List (CRL).

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Educating Retirees About Creditable Coverage

Ms. Hesseltine explained that, per the Medicare Modernization Act (MMA), Plan Sponsors are required to send a Creditable Coverage Notice to notify Medicare eligible policyholders whether their prescription drug coverage is "creditable coverage," as well as whether their prescription drug coverage is expected to pay on average as much as the standard Medicare prescription drug coverage.

Plan Sponsors are required to provide a written disclosure notice to all Medicare eligible individuals annually who are covered under the Plan Sponsor's prescription drug plan prior to October 15 and at various times as stated in the regulations, including when a Medicare eligible individual joins the plan. The disclosure is to be provided to Medicare eligible active working individuals and their dependants, Medicare eligible COBRA individuals and their dependants, Medicare eligible disabled individuals covered under the Plan Sponsor's prescription drug plan, and any retirees and their dependants.

Participants were encouraged to use this opportunity to educate beneficiaries about the Plan Sponsor's Prescription Drug Plan and RDS by:  

  • Explaining that the Plan Sponsor's plan has equivalent or better drug coverage than Medicare Part D, and beneficiaries do not need Medicare Part D.
  • Explaining that beneficiaries cannot have both Medicare Part D and the Plan Sponsor's plan; therefore, beneficiaries should not enroll in a Part D plan.

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Establishing Qualifying Covered Retirees Early

Ms. Hesseltine explained that a Qualifying Covered Retiree (QCR) is:

  • A retiree of the Plan Sponsor or a retiree's spouse or dependant.
  • Covered under the Plan Sponsor's Qualified Retiree Prescription Drug Plan.
  • Eligible for, but not enrolled in, a Medicare Part D Plan.

To establish QCRs, Plan Sponsors need to submit both the application and the Valid Initial Retiree List. CMS' RDS Center will use information available through MBD to determine if beneficiaries are eligible for subsidy for any of the drug plan coverage period, as well as to calculate subsidy periods.

Participants were encouraged to establish QCRs early so that retirees are "flagged" in the MBD as RDS participants. As a result, the QCRs will be initially rejected from Medicare Part D should they attempt to enroll during OEP. Medicare Part D Enrollment Rejection Notifications will display on the RDS SWS and will be bundled into the Weekly Notification File, prompting Plan Sponsors to contact beneficiaries before they attempt to enroll in Part D again.

Tip: Submit the application and Valid Initial Retiree List as soon as possible—ideally before the beginning of OEP.

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Monitoring and Managing Qualifying Covered Retirees

RDS Exchange of Retiree Information

Ms. Hesseltine reviewed how the exchange of retiree information works in RDS for Plan Sponsors to monitor and manage Qualifying Covered Retirees (QCRs):

Submit Valid Initial Retiree List and Application

To define how to exchange retiree information with CMS' RDS Center, the Plan Sponsor selects Electronic Data Interchange (EDI) methods and sources during the Application Submission Process. Then, the Valid Initial Retiree List can be submitted. CMS' RDS Center receipts the file and checks the format. If the format is valid, Step 9 of the Application Submission Process indicates that the file has been received. CMS' RDS Center then holds the file until the application is submitted.

Note: Submitting both the Valid Initial Retiree List and the application before the Application Deadline is the prompt for CMS' RDS Center to start verifying the Valid Initial Retiree List.

Validate Valid Initial Retiree List and Flag RDS Beneficiary

To validate the Valid Initial Retiree List, CMS' RDS Center sends the retiree information to MBD. MBD looks for the beneficiary in its database based on the information the Plan Sponsor supplied such as Social Security Number, Health Insurance Claim Number (HICN), Date of Birth, and Gender. If it finds a match, MBD records in its database that the beneficiary is of interest to RDS. MBD then tells CMS' RDS Center whether or not the retiree, spouse, or dependant is eligible for Part D but not enrolled in Part D for the drug coverage period sent in the retiree file. It also sends CMS' RDS Center specific enrollment and entitlement dates for the beneficiary, such as when the beneficiary became eligible for Part D, enrolled in Part D, dis-enrolled from Part D, and Date of Death.

Calculate Subsidy and Create Response

Based on the information supplied by MBD, the Plan Sponsor's application plan year dates, and the drug plan coverage dates sent in the retiree file, CMS' RDS Center calculates the begin and end dates of the subsidy period for each QCR and creates a Response File. The Response File contains the exact retiree data that was sent to CMS' RDS Center, along with a few additional columns that indicate whether or not a subsidy period was approved for the beneficiary and the calculated subsidy period. The reason codes included in the file explain why a beneficiary did not qualify for subsidy or did not qualify for the entire coverage period requested. The Plan Sponsor or Vendor is expected to process the Response File to update their internal records, research rejections, and resolve discrepancies.

Note: The Plan Sponsor or Vendor should continue to send retiree list additions, updates, or deletions as enrollment changes throughout the application's lifecycle, especially prior to reporting costs and requesting payment.

Notify RDS and Plan Sponsor/Vendor

Notifications are unsolicited responses to events occurring in the MBD. When an event (such as enrollment in Part D) occurs for an RDS QCR that may affect a beneficiary's entitlements or enrollments, MBD sends a notification to CMS' RDS Center. Some events trigger a recalculation in the subsidy period, while others are informational. 

Notifications about attempted enrollments in Part D are sent to the RDS SWS daily. Additionally, CMS' RDS Center sends Weekly Notification Files to Plan Sponsors if a change has occurred to a QCR at MBD.

It is essential to process both Response Files and Notification Files so the Plan Sponsor's records accurately reflect RDS QCRs. This is important because the Plan Sponsor can only report costs for QCRs and their approved Benefit Options and subsidy periods.

Tip: To maximize subsidy, review Response and Notification Files and research rejections well before Reconciliation.

Request the Covered Retiree List

A Covered Retiree List (CRL) is a point in time snapshot of QCRs. It can be requested on the RDS SWS by the Account Manager, Authorized Representative, or Designee with View/Send/Receive Retiree Data privilege once the application is approved. The CRL only contains the approved QCRs and their Benefit Options and subsidy periods.

Note: To find out why subsidy was rejected for a beneficiary, refer to the Response and Notification Files.

How to Monitor and Manage QCRs 

Ms. Hesseltine explained that Plan Sponsors can monitor and manage QCRs by:

  • Reviewing and processing Retiree Response Files, ensuring to investigate any records with a reason code greater than 00.
  • Viewing Part D Rejection Notifications on the RDS SWS, especially during OEP, and contacting beneficiaries immediately to prevent them from enrolling in Part D.
  • Reviewing and processing Weekly Notification Files and resending retiree records to CMS' RDS Center as needed, depending on the reason code(s) received.
  • Frequently requesting and reviewing the CRL, verifying it against internal records, and sending it to Cost Reporters to compile costs only for the QCRs contained in the CRL and their approved subsidy periods.
  • Keeping the retiree list up-to-date by sending changes to CMS' RDS Center throughout the plan year. 

Reviewing Response Files

Participants were shown an example of a Response File and provided some tips for reviewing it. Ms. Hesseltine recommended adding a header to the file for readability, then sorting/filtering the file by Determination Indicator and Reason Code. Reason Code 00 can be ignored, as this code indicates that the entire subsidy request was granted by CMS' RDS Center. However, any records with the Determination Indicator 'N' or a reason code greater than 00 should be reviewed and acted on as needed. Plan Sponsors can only report costs for beneficiaries with Determination Indicator 'Y' and only the costs accrued during the approved subsidy period.

Reviewing Notification Files

Participants were provided an example of a Notification File with reason codes that may be sent during OEP. Included in a Notification File are Part D Rejection Notifications, which tell Plan Sponsors when a QCR attempted to enroll in Part D. Notifications are posted to the RDS SWS daily, and CMS' RDS Center also includes rejection notifications in Weekly Notification Files (the Plan Sponsor receives an email when a file is available). The Account Manager, Authorized Representative, and Designee with View/Send/Receive Retiree Data privilege can access notifications either by downloading Weekly Notification Files or by viewing notifications on the SWS.

Ms. Hesseltine encouraged participants to check the RDS SWS daily during OEP in order to be proactive. Part D Rejection Notifications are a Plan Sponsor's cue to contact beneficiaries who tried to enroll in Part D and educate them about their Prescription Drug Plan and RDS.

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CMS' RDS Center Hot Topics

Participants reviewed several CMS' RDS Center hot topics:

  1. Turning the CRL Into a Valid Initial Retiree List

    The following tips were provided for Plan Sponsors planning to use a CRL from their previous application to build their Valid Initial Retiree List:

    • Update Column A to reflect the new Application Number
    • Update Column I and Column J to reflect the new Plan Year
    • Make sure the Unique Benefit Option Identifier (UBOI) in Column K reflects the UBOI on the new application
    • Delete all columns after the Transaction Type
  2. Maintaining an Active Account

    Participants were reminded that Federal Security Regulations require all registered RDS Secure Website users to maintain an active user account. Both the Account Manager and the Authorized Representative must be active to receive payments, submit an application, and complete Reconciliation.

  3. Top Response File Reason Codes

    Participants were shown top Response File Reason Codes:

    Reason Code 10/Determination Indicator = 'Y': The beneficiary has enrolled in Part D, and subsidy was approved for a portion of the requested coverage period. If the Plan Sponsor wants to expand the coverage period, it should contact the beneficiary. The beneficiary will need to dis-enroll from Part D. Once the Plan Sponsor receives a Reason Code 21 notification, it should resend the retiree record to CMS' RDS Center.

    Reason Code 10/Determination Indicator = 'N': The beneficiary has enrolled in Part D and is not eligible for subsidy for any of the period requested. The Plan Sponsor should contact the beneficiary. The beneficiary will need to dis-enroll from Part D. Once the Plan Sponsor receives a Reason Code 21 notification, it should resend the retiree record to CMS' RDS Center.

    Reason Code 11/ Determination Indicator = 'Y' or 'N': The beneficiary is not eligible for Part D for all or some of the requested coverage period. The beneficiary has probably not aged into Medicare yet. The Plan Sponsor should check the Date of Birth.

    Reason Code 16/Determination Indicator = 'N': The beneficiary was not found at MBD. Most likely some identifying information does not match MBD. The Plan Sponsor could try using the Social Security Number (SSN), Health Insurance Claim Number (HICN), or Date of Birth of the retiree's spouse or dependant; sending the SSN or HICN, but not both; having the beneficiary call 1-800-Medicare.

  4. Top Notification File Reason Codes

    Ms. Hesseltine also reviewed top Notification File Reason Codes:

    Reason Code 10/Determination Indicator = 'Y': The beneficiary has enrolled in Part D and subsidy is still approved for a portion of the requested coverage period. If the Plan Sponsor wants to expand the coverage period, it should contact the beneficiary. The beneficiary will need to dis-enroll from Part D. Once the Plan Sponsor receives a Reason Code 21 notification, it should resend the retiree record to CMS' RDS Center.

    Reason Code 10/Determination Indicator = 'N': The beneficiary was qualified for subsidy but has now enrolled in Part D. The beneficiary is no longer eligible for subsidy for any of the period requested. The Plan Sponsor should contact the beneficiary. The beneficiary will need to dis-enroll from Part D. Once the Plan Sponsor receives a Reason Code 21 notification, it should resend the retiree record to CMS' RDS Center.

    Reason Code 20/Determination Indicator = Blank: The beneficiary attempted to enroll in Part D but was initially rejected. The Plan Sponsor should contact the beneficiary.

    Reason Code 21/ Determination Indicator = Blank: New Medicare information is available (i.e., dis-enrolled from Part D). The Plan Sponsor should resend the retiree record to CMS' RDS Center with the latest coverage information.

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Resources Related to This Webinar

Upcoming Webinars

Plan Sponsors and Vendors are encouraged to monitor the RDS Program Website for announcements about upcoming webinars.

Need Assistance?

If you have questions or need additional information, contact CMS' RDS Center.