Program of All-Inclusive Care for the Elderly (PACE) Organizations

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1 DEPA RTM EN T OF H EA LTH & H UM A N SERVICES Centers for M edicare & M edicaid Services Center for M edicare 7500 Security Boulevard Baltimore, M aryland MEDICARE DRUG & HEALTH PLAN CONTRACT ADMINISTRATION GROUP DATE: October 19, 2012 TO: FROM: SUBJECT: Program of All-Inclusive Care for the Elderly (PACE) Organizations Danielle R. Moon, J.D., M.P.A. Director Medicare Enrollment for PACE Participants with Prospective or Retroactive Medicare Entitlement The purpose of this memorandum is to provide guidance regarding Program of All-Inclusive Care for the Elderly (PACE) participants who do not have Medicare at the time of their initial PACE enrollment and subsequently obtain it. As specified in CMS regulations at 42 CFR 460 et seq., individuals are eligible to enroll in PACE even if they are not entitled to Medicare. However, if and when these individuals become eligible for Medicare, they must obtain all Medicare services, including Part D prescription drug coverage, through the PACE organization. Therefore, it is important that PACE organizations track the Medicare entitlement of their participants and ensure that they are enrolled in PACE in CMS systems upon entitlement or, in cases where Medicare entitlement and/or enrollment is retroactive, shortly thereafter. For more information on these requirements, please see our HPMS Memorandum of December 24, 2009, Retroactive Enrollment/Disenrollment Implementation Guidance for PACE Organizations - CORRECTED. In addition, beginning January 1, 2013, PACE organizations must notify participants that, should they become entitled to Medicare, they must receive all Medicare-covered services through the PACE organization or disenroll from the PACE organization, as follows: 1. Notification via the PACE Enrollment Agreement PACE organizations must advise newly enrolled PACE participants who are not yet Medicare eligible that their Medicare benefits, should they become eligible, will be assigned to and received from the PACE organization. Therefore, we are adding the following to the list of information (enumerated at section 30.5 of the PACE Manual) to be included, at a minimum in the enrollment agreement: Notification that a participant who becomes eligible for Medicare after enrollment in PACE must obtain all Medicare coverage (Parts A and/or B, and Part D) from the PACE organization. 1

2 This notification is designed to ensure that the participant is involved in the election process and is aware of his/her options. 2. Notification Prior to or Following Medicare Entitlement In addition, PACE organizations must provide participants with a 60-day advance notice of their ability to opt out of PACE prior to enrolling them as Medicare PACE participants. (See attachments A and B for two model letters that may be used for this purpose.) PACE organizations may supplement this written notification with a phone call or other counseling to the participant. Submission of Enrollment Transaction to CMS As a reminder, PACE organizations must submit an enrollment transaction on behalf of the member in accordance with the requirements described in Attachment C. If you have any questions about this guidance, please send an to CMS PACE_Comments@cms.hhs.gov. 2

3 Attachment A: PACE Model Letter #1 Prospective Medicare Entitlement/Enrollment This model is to be used when an existing PACE participant is prospectively entitled to and/or enrolled in Medicare and must be furnished at least 60 days in advance of the Medicare PACE enrollment effective date. Although participants are asked to respond within 30 days of the letter, PACE organizations must accept opt out requests through the last day of the month immediately preceding the proposed Medicare PACE enrollment effective date. Dear (PACE participant): We understand that you will soon have Medicare. As a reminder, [insert PACE organization name] will cover all Medicare services including: Medicare Part A (hospital insurance), Part B (medical insurance) and Part D (prescription drug coverage). Do nothing if you want to stay with [insert PACE organization name] to get your Medicarecovered services. We will tell Medicare and you will stay enrolled with us. However, if you don t want your Medicare services through us, you must disenroll from [insert PACE organization name].. Please call us within 30 days of this letter if you want to leave [insert PACE organization name] so that we can ensure that you are disenrolled from [insert PACE organization name] in a timely manner. A counselor will tell you how to disenroll from [insert PACE organization name]. If you decide later that you want to leave [insert PACE organization name], you can call us at [insert PACE organization name] or call MEDICARE ( ) to learn more about your Medicare options. Please note that, if you decide to leave [insert PACE organization name] in the future, your disenrollment will be effective the first of the month after the month in which we receive your request. Sincerely, Enrollment Coordinator 3

4 Attachment B: PACE Model Letter #2 Retroactive Medicare Entitlement/Enrollment This model is to be used when an existing PACE participant is retroactively entitled to or enrolled in Medicare. Dear (PACE participant): We understand that you recently got Medicare. As a reminder, [insert PACE organization name] will cover all Medicare services including: Medicare Part A (hospital insurance), Part B (medical insurance) and Part D (prescription drug coverage). Your Medicare coverage will start with us as of <insert date> and your Medicare Prescription Drug Coverage will start on <insert date>. Do nothing if you want to stay with [insert PACE organization name] to get your Medicarecovered services. We will tell Medicare and you will stay enrolled with us. However, if you don t want your Medicare services through us, you must disenroll from [insert PACE organization name]. Please call us within 30 days of this letter if you want to leave [insert PACE organization name] so that we can ensure that you are disenrolled from [insert PACE organization name] in a timely manner. A counselor will tell you how to disenroll from [insert PACE organization name]. If you decide later that you want to leave [insert PACE organization name], you can call us at [insert PACE organization name] or call MEDICARE ( ) to learn more about your Medicare options. Please note that, if you decide to leave [insert PACE organization name] in the future, your disenrollment will be effective the first of the month after the month in which we receive your request. Sincerely, Enrollment Coordinator 4

5 Attachment C: Enrollment Scenarios Scenario 1 -- Prospective Medicare Entitlement In addition to providing the advance notice as described in the memo, the organization must submit an enrollment transaction to the Medicare Advantage Prescription Drug (MARx) enrollment system no less than 60 days prior to the effective date of Medicare PACE enrollment. The following data elements must be provided on the transaction (along with all other standard required fields): Provided the 60-day advance notice requirement is met, the effective date of Medicare PACE enrollment is equal to the effective date of Medicare entitlement. The application date for these specific transactions is equal to the 1 st day of the 2 nd month prior to the effective date of the Medicare PACE enrollment. The Election Type code is equal to S to indicate a Special Enrollment Period for Individuals Enrolled in PACE. Example: Ms. Jones is currently enrolled in PACE. She will attain age 65 in October 2013 and will become entitled to Medicare Part A and enrolled in Part B as of October 1, The PACE organization provided the notification required on or before August 1, On August 2, 2013, the PACE organization submits an enrollment transaction to MARx to enroll Ms. Jones into PACE in Medicare s systems. That transaction has the following data elements (including all other required fields): Effective date = 10/01/2013 Application date = 08/01/2013 Election Type = S. It is expected that the PACE organization be knowledgeable about its participants health status or conditions so as to anticipate Medicare entitlement for End Stage Renal Disease or disability. In the event that the prospective Medicare entitlement for eligibility other than age not be anticipated by the PACE organization, the retroactive process described below should be implemented. Scenario 2: Retroactive Medicare entitlement: PACE participant obtains retroactive Medicare entitlement. In these circumstances, the PACE organization cannot submit a transaction to MARx directly. Rather, PACE organizations must contact their Regional Office (RO) Account Manager (AM) and provide them with the necessary information to request Medicare PACE enrollment for the appropriate retroactive effective date, including the data elements described above in Scenario 1. The RO AM may request additional information and/or documentation to support the request. 5

6 The effective date of enrollment may be up to 1 (one) year retroactive to the month in which the request is received by the RO AM. Requests for retroactivity are limited to cases where the individual receives a retroactive Medicare entitlement award from the Social Security Administration or becomes entitled to Medicare for a reason other than age (e.g., disability, ESRD) that was not immediately identified and addressed following the requirements in Scenario 1 above. Special Note Regarding Part D Eligibility In accordance with CMS regulations at 42 CFR (a) (3), Part D eligibility is not retroactive. For individuals who become entitled to Medicare Part A or enrolled in Medicare Part B retroactively, Part D eligibility begins with the month in which the individual is notified of the retroactive entitlement or enrollment. Therefore, PACE participants who are dually eligible continue to receive prescription drug coverage through Medicaid until their Part D eligibility begins. The effective date of Medicare PACE enrollment can begin with the effective date of entitlement to Medicare Part A and/or enrollment in Part B (up to one year retroactive). The MARx system will automatically include the Part D capitation beginning with the first month of Part D eligibility. Example: Mr. Smith is currently a PACE participant with Medicaid. In October 2013, Mr. Smith receives notification from the Social Security Administration (SSA) that he is entitled to Medicare Part A effective January 1, 2013 and he is enrolled in Medicare Part B effective October 1, Medicare Part D eligibility begins October 1, The PACE organization requests retroactive Medicare PACE enrollment by contacting the RO AM with all the necessary information on October 29, The PACE organization requests an enrollment effective date of January 1, This is acceptable because it is not greater than one year prior to the date the request is received by the RO AM, and Mr. Smith has Medicare Part A as of this date. The RO AM will enter a Medicare PACE enrollment into MARx effective January 1, The PACE organization will receive payment for Part A going back to January 2013, Part B will be added as of June 2013, and Part D as of October Possible Conflicting Enrollments Please note that taking the enrollment actions described above may conflict with other already existing plan enrollments, such as automated or facilitated Medicare Part D enrollments for full dual-eligible beneficiaries. Therefore, the PACE organization should use the Beneficiary Eligibility Query (BEQ) to check CMS systems for other prior enrollments before effectuating a retroactive enrollment. If there is such a conflict, the case should be referred to the RO to determine the beneficiary s preference and provide options. 6