Guest Column | March 2, 2016

May The Good Cause Be With You!

Medicare ACO

By Jaydev Rajnikant Doshi, Business Manager, Virtusa

CMS continuously strives to improve the healthcare services standard across organizations offering Medicare/Medicaid coverage plans. As part of the same endeavor, the organization came up with a list of changes for the Medicare Advantage (MA) program (Part C) and Prescription Drug benefit program (Part D) of Medicare for contract year 2016. One of the key changes, part of the CMS mandate (CMS-4159-F2), pertains to Good Cause Reinstatement (GCR) decisions:

“As of January 1, 2016, individuals dis-enrolled for non-payment of plan premiums who wish to request reinstatement for good cause will be directed to contact the plan from which they were dis-enrolled.”

Simply speaking, CMS is giving the power to make decisions related to GCR to individual organizations managing the complaints related to the Medicare program. This shift in decision-making responsibility signifies a change in the complaints management approach at CMS, with the focus being on monitoring and rating agencies rather than functioning as a channel of inquiry for members. So what does this change mean for the organizations offering Medicare Prescription Drug benefit program (Part D)?

As of the first of the year, CMS has stopped accepting any GCR requests from members and is instead instructing them to call their respective health plan organization for getting their reinstatement requests processed. This was previously accepted by CMS. Any decision regarding GCR was evaluated by coordinators at CMS who would later send across the request to corresponding health plan companies, who were to reinstate members within five working days upon receipt of the request. Changes in the process due to this new mandate are as follows:

Outbound Communication Related To Member Termination

Any outbound communication related to member termination has a FAQ section detailing the steps to take if a member feels he has a justifiable reason to be reinstated. The new process will lead to a change in these templates. New reference templates are provided by CMS and can be found here. The impacted correspondence templates can be found in Exhibit 21, Exhibit 22a, Exhibit 22b and Exhibit 22c.

Interaction Guidelines From CMS

In order to facilitate the smooth transitioning of GCR processing from CMS to individual health plan organizations, as well as maintain the standard of interactions, CMS conducted a series of exploratory sessions with all the stakeholders and consolidated a list of Frequently Asked Questions and has provided a reference flow chart to help coordinators from various organizations have a high level script they can follow while interacting with members.

New Process For Managing The Incoming GCR Request

In order to manage member requests, health plan companies need to tweak their existing work processes where the only interaction with CMS was based on the Complaints Tracking Module. They now need to have an interface for the members to reach them directly and log their requests. This may have a long-term impact: CMS can further decentralize pieces of the Complaints Tracking Module to be managed individually by the companies.

Audit Requirements Related To GCR Process

As part of the modified process, CMS will also be conducting timely audits to analyze the level of compliance across organizations. This requires companies to maintain a record of interactions with members, decisions taken for the good cause request along with the justification (in both scenarios, Accepting the Good Cause or Rejecting it), call attempts made, payment received date, etc.

Impact On Star Ratings Based On GCR Request Servicing

The decision-making process of each individual company will defer in their execution and in order for them to adhere to the standards, CMS has decided to give members an option to complain against the process carried out by health plan companies. It should be noted that members cannot challenge the decision taken, but only complaints against the processes followed. Decisions taken by the health plan companies are final. These complaints however, will be used to evaluate the service quality of the companies and will have an impact on the Star ratings provided by CMS for the health plans.

About GCR Process

A GCR is a special provision provided by CMS to Medicare members, where a member who is dis-enrolled due to non-payment of premiums can request a reinstatement owing to certain exigent circumstances at their end. The request is to be made within 60 days of disenrollment. CMS has a list of predefined circumstances which are considered exigent some of which are:

  • Federal government error caused the payment to be missed or late;
  • prolonged illness, hospitalization or institutionalization of the beneficiary;
  • death or serious illness of spouse or other family member; or
  • loss of the beneficiary’s home or severe impact by fire, or other exceptional circumstance outside the beneficiary’s control (e.g. affected individual resides in a federal disaster area).