The Retiree Drug Subsidy (RDS) Community Information Group (CIG) hosted a webinar on Wednesday, November 13, 2013. Over 415 individuals attended the webinar allowing them to stream audio and view presentation slides.
The webinar was presented by Jennifer Craft, Manager of the Education, Training, and Outreach Division of CMS' RDS Center.
Webinar Topics:
Retiree Processing Basics
Participants were provided an overview of Retiree Processing that included submitting files to CMS' RDS Center and processing Retiree Response Files and Retiree Notification Files from CMS' RDS Center. Plan Sponsors were reminded that the goal of retiree processing is to establish and maintain their Qualifying Covered Retirees (QCRs) throughout the plan year and not just during Reconciliation. Participants were provided the following definition: a QCR must be (1) a retiree of the Plan Sponsor or a retiree's spouse/dependants; (2) a person covered under the Plan Sponsor's Qualified Retiree Prescription Drug Plan and (3) a person eligible for but not enrolled in a Medicare Part D plan.
How CMS' RDS Center Calculates Subsidy Periods
Participants were shown examples of the data used in the calculation of Subsidy Periods and the subsequent outputs or results of Subsidy Period calculations including Subsidy Period Effective and Termination Dates, Determination Indicators and Reason Codes.
Examples of both a Retiree Response File and Retiree Notification File were presented along with an example of a Retiree Response File in Excel format. Finally, Reason Codes generated on each type of file were reviewed and examples provided to participants.
Recommended resources related to this topic:
Reviewing and Decoding Response and Notification Files
Participants were advised of tips, tools and best practices to utilize when processing Retiree Response Files and Retiree Notification Files. Tips included using the import wizard when importing files to Microsoft Excel (or any other spreadsheet tool) vs. just opening the file. Importing the file helps avoid losing the leading zeros on fields that look like numbers. Participants were encouraged to sort Response and Notification Files by Reason Codes and Determination Indicator. Ms. Craft also recommended using the spreadsheet's filtering features to “hide” all of the rows with Reason Code 00 as this code indicates that the entire subsidy request was granted by CMS' RDS Center. Participants were also advised that Account Managers and Designees with Retiree Data Privilege receive an email when Retiree Response and Notification Files are available.
The following Reason Codes, typical causes, and troubleshooting suggestions were provided:
Reason Code 10: Retiree is enrolled in a Medicare Part D. This may have happened due to confusion on the part of the beneficiary or someone who has legal authority over their benefits. Plan Sponsors should work with that person to make sure they understand that the Plan Sponsor's benefits are as good as or better than Medicare Part D. If the person believes they are erroneously enrolled in a Medicare Part D plan, the beneficiary must contact 1-800-Medicare to correct the situation. The Plan Sponsor may not contact Medicare on behalf of the beneficiary but may conference call with them to aid in resolving any confusion.
Reason Code 11: Retiree is not eligible for Medicare Part D. This person was found in the Medicare database but for some reason is not eligible for Medicare Part D. Many times Plan Sponsors receive this code because the beneficiary has not yet “aged into” Medicare. Plan Sponsors should first check the retiree's date of birth. In most cases the retiree will only be eligible for Medicare when they turn 65. Many Plan Sponsors allow a retiree to enroll in their RDS benefits even if their 65th birthday is sometime in the next year. If the issue is not related to birthdates and the retiree believes they are eligible for Medicare Part D, they must contact 1-800-Medicare to correct the situation. The Plan Sponsor may not contact Medicare on behalf of the beneficiary but may conference call with them to aid in resolving any confusion.
Reason Code 12: Retiree is deceased. This person was found in the Medicare database but has a date of death that falls within the period for which the Plan Sponsor is requesting subsidy. This information is rarely incorrect but your benefits staff may want to reach out to the retiree's family to discuss the benefits situation. Any discrepancies related to the date of death must be addressed with the Social Security Administration.
Reason Code 16: Beneficiary not found in Medicare database. The identifying information provided in the retiree file did not match any of the beneficiaries in the Medicare database. This could happen because the retiree has not yet registered with Medicare but is more likely due to a flaw in the data provided. Plan Sponsors should validate the Social Security Number, Health Insurance Claim Number (HICN), date of birth, and gender. When submitting a spouse or dependant, confirm that you are submitting the beneficiary's data and not that of the retiree. Validate all data that you are able to by viewing the beneficiary's Medicare Card. If the person has a Medicare Card they should be in the Medicare database. Correct any data issues and submit the beneficiary to CMS' RDS Center. If the issue persists the beneficiary must contact 1-800-Medicare to correct the situation. The Plan Sponsor may not contact Medicare on behalf of the beneficiary but may conference call with them to aid in resolving any confusion.
Reason Code 20: Retiree has attempted to enroll in a Medicare Part D plan. When a retiree is already an RDS QCR and they attempt to enroll in a Medicare Part D plan they will be initially rejected. On the RDS Secure Website (SWS) they will be listed on the “Medicare Part D Enrollment Rejection Notifications” screen that is accessed from the Manage Retirees page. The Plan Sponsor will also receive a notification in their Weekly Notification File. This may have happened due to confusion on the part of the beneficiary or someone who has legal authority over their benefits. Plan Sponsors should work with that person to make sure they understand that the Plan Sponsor's benefits are as good as or better than Medicare Part D. If the person persists, they will be enrolled in a Medicare Part D plan on their next attempt.
Reason Code 21: Retiree has a potential for expanded subsidy. When a retiree becomes eligible for a potential expansion in subsidy, the Plan Sponsor will receive a row with this reason code in a Notification File. The Plan Sponsor should submit the beneficiary to CMS' RDS Center. Subsidy will be recalculated and the Subsidy Periods will be created based on current Plan Sponsor coverage and Medicare Part D entitlement and enrollments. CMS' RDS Center will not expand subsidy unless the retiree is submitted again. To avoid missing out on potential subsidy payments, Plan Sponsors are encouraged to monitor their Notification files for code 21.
Understanding the Covered Retiree List (CRL)
Participants were reminded that the CRL contains only the Qualifying Covered Retirees approved for subsidy. The file is generated in a .CSV format and contains every field found in both the Retiree Response File and Retiree Notification File along with 2 additional fields – Method and Source. Participants were educated on how to request the CRL on the RDS Secure Website (SWS) by accessing the Manage Retirees page since the CRL is not automatically generated like the Response or Notification files. Participants also examined key elements of a sample CRL file.
Coordinating Retiree Data with Internal and External Sources
How Covered Retiree Counts Can Help
Participants were shown examples of how to use the RDS Covered Retiree Counts to look for big discrepancies between the RDS records and their enrollment and cost reporting systems. Plan Sponsors were encouraged to track and monitor changes in retiree counts to look for potential issues. Examining these counts at Application and Benefit Option levels allows Plan Sponsors to identify areas worthy of further research using the CRL or Retiree Response and Notification files.
Timing on Getting Involved
Participants were advised to manage retirees throughout the plan year – not just at Reconciliation. However, it is especially important in preparation for a payment request whether the request is interim or final. Keep in mind that costs may only be reported for QCRs, Benefit Options, and Subsidy Periods listed in the CRL.
Recommended resources related to this topic:
- Covered Retiree List and Interim Cost Reporting - Communicating the Covered Retiree List (CRL) is an essential part of RDS participation
- Timeline of Events Job Aid – Illustration of a typical Reconciliation timeline and a helpful diagram for participants to customize Application timelines
- Task List and Assignments Job Aid – Similar to a project plan, this will assists participants with assignments and prioritization of key Reconciliation tasks
Matching RDS Covered Retiree Counts to your Enrollment System
Participants were reminded of the importance of matching RDS Covered Retiree Counts to their enrollment systems to ensure all possible subsidy dollars are utilized. Plan Sponsors should make sure that they have submitted all retirees that are covered under their RDS benefit plans. Plan Sponsors should identify retirees that have not been granted subsidy – or have been granted partial subsidy and work to resolve any data discrepancies that are causing that situation. Participants were advised to verify Current Covered Retiree Counts to identify any major gaps then use the Retiree Response and Notification files to identify specific retirees. After all retirees receiving benefits have been assigned subsidy or the Plan Sponsor can identify why they are not receiving subsidy, it is alright to move to the next verification step – matching Covered Retiree List to your cost reporting system.
Matching RDS Covered Retiree Counts to your Cost Reporting System
Having reconciled the RDS Qualifying Covered Retirees with the enrollment system Plan Sponsors must then make sure the systems used to report cost data to CMS' RDS Center are also in sync. Providing the CRL to Cost Reporters is the first step but validating that all the data in that list got uploaded to the cost reporting system is equally important. Both humans and systems interact with the CRL throughout the process so errors can happen. Participants were reminded to identify big discrepancies using RDS Covered Retiree Counts and then use the Covered Retiree Lists to resolve any issues. When the cost reporting system contains all of the QCRs, Benefit Options, and Subsidy Periods means that the most accurate subsidy payments can be calculated.
Remember, the CRL always wins!
Managing Retirees After Reconciliation Has Been Initiated
Participants were encouraged to manage retiree data all year and not wait until the Reconciliation period. If managed all year, at Reconciliation, little-to-no changes or validation will be required for Qualifying Covered Retirees (QCRs). To complete Reconciliation Step 3, the CRL must be requested on that step in the Reconciliation Checklist; the RDS system will not recognize CRLs requested on the Manage Retirees page for purposes of Reconciliation. Reconciliation Step 4 requires the Account Manager or Authorized Representative to commit to the Covered Retiree List and verify that costs will only be submitted for the QCRs, Benefit Options, and Subsidy Periods listed in that Covered Retiree List. It is imperative that the Plan Sponsor communicate the content of the Cost Preparers and Cost Reporters.
Recommended resources related to this topic:
Changes in EDI Method
If a Plan Sponsor has a change in the way they exchange retiree information with CMS' RDS Center or is working with a new submitter (Vendor or PBM), they should review the EDI Methods and Sources Job Aid: a tool for Plan Sponsors and Vendors to effectively change Retiree Electronic Data Interchange (EDI) Methods or Sources on Applications with Qualifying Covered Retirees (QCRs) and to understand the impact of EDI Methods and Sources
Other Retiree Processing Resources
- How To Use The Sample Retiree File Spreadsheet: Instructions for Plan Sponsors and Vendors utilizing the Editable Sample Retiree File Spreadsheet
- Editable Sample Retiree File Spreadsheet: Tool to assist Plan Sponsors and Vendors with creating and uploading retiree file to CMS' RDS Center and the RDS Secure Website
Upcoming Webinars
Participants were encouraged to attend the next RDS CIG webinar. Webinars are presented several times in the calendar year, corresponding with key Application and Reconciliation landmarks. Monitor the Events page of the RDS Program Website for announcements about upcoming webinars.
The Reconciliation Part 3: Working with Cost Reporters at Reconciliation webinar is scheduled for December 18, 2013.
If you have questions or need additional information, contact CMS' RDS Center.