The Bridge – Volume 9


October/November CMS Software Release: Impacts to Plans


Jennifer Young

Jennifer Young, Executive Vice President, Healthcare Operations

The October CMS Software HPMS memo dated 9/1/2020 has some interesting changes, and the implementation time frames are compressed. Health plans must implement the additional data elements for Preferred Language and Accessible Format by 10/15/2020. Any new 2021 enrollment (TC61) will need to include these data fields but are listed as optional. The fields must be “optional” because an alternative language or format does not apply to all members. However, the implementation of these data elements in your enrollment submission is not optional. CMS expects health plans to comply with these changes and send the pertinent information when a member completes those fields on the enrollment application.

In coordination, there is an additional TC92 and other TRC codes to support ‘personal information changes’ as well as the CMS response to whether the transaction is accepted or rejected. The TC92 transactions, like the data elements for the TC61, are required for health plans to implement in their systems, data extract logic for the MARx Input File, and systems that process the Transaction Reply Report. The TC92 transactions are post-enrollment and do not follow the CPM or CCM submission timeframes; submissions today will be effective the first day of the month the submission was accepted by CMS.

What CMS does not say is why this information is needed and how it will be used. In our experience, CMS collects and gathers data elements to perform compliance analysis. Health Plans could receive a “TAL”, or Technical Assistance Letter, notifying them that they have failed to implement the changes based on a lack of these data elements on the TC61 or a lack of use of the TC92 personal information change transactions. We would also expect that CMS may add this to their new “Informal Operational Reviews” in 2021 or 2022.

Bottom line: Based on the OIG’s call for greater CMS oversight of MA plans, if this is a new requirement, expect that there is an oversight process coming down the pipe.

Reach out to Madena’s expert team if you need assistance with these changes.


August HPMS Memo Summary

Sara King, Senior Business Analyst

The August HPMS memos brought additional guidance for 2021 OEC, news of software system changes for MARx Enrollment, and LIS redeterminations.

Announcement of the October 2020 Software release – Enrollment Transaction

This memo provides information regarding a systems change scheduled for the October 2020 release – System Change: New Fields for MARx Enrollment Transaction

Re-Determination of Part D Low-Income Subsidy Eligibility for 2021

The Part D LIS provides extra help for people with Medicare who have limited income and resources by helping to pay their Medicare Prescription Drug Benefit costs (plan monthly premiums, co-payments, and the annual deductible). Read the memo here.

Additional Guidance for the Contract Year (CY) 2021 Online Enrollment Center (OEC)

This memo provides supplemental guidance for the OEC regarding: (1) plan testing of the new CY 2021 record layout; and (2) the timeline to opt-in to participate in the CY 2021 OEC.

Contract Year (CY) 2021 Online Enrollment Center (OEC) Application Programming Interface (API)

Beginning with CY 2021, CMS will provide organizations and their contracted third party vendors and consultants an additional mechanism for downloading OEC enrollments from HPMS. Read the updates here.

As always, if you need help applying changes or updating systems, contact Madena for assistance.

BIC-BEQ API Implementation

Mike Gilliland, COO

Madena is excited to kick off our first implementation of CMS’ new BIC-BEQ REST API for one of our MAPD clients. Based on the June 5th memo from CMS, MAPDs can leverage these APIs to retrieve the following:

  • Demographics
  • Entitlement/eligibility
  • Part D employer subsidy
  • Low Income Subsidy (LIS)
  • End Stage Renal Disease (ESRD)
  • Uncovered months
  • Enrollments
  • Ineligibility due to not lawful presence or incarceration
  • Comprehensive Addiction and Recovery Act (CARA) details
Integrating these APIs with the Eligibility Business rules in Madena’s Membership Suite™ system allows us to help our clients reduce eligibility processing time by moving the existing BEQ Batch process to a near real-time eligibility verification service.
If your organization is interested in learning more about integrating your BEQ process with CMS’ new BIC-BEQ API, contact Madena today.


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