Public Comments

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Regulatory Operations Comment Form

Section/Title

Commentor

Functional Area

Comment(s)
I would like to take this opportunity to address CMS time estimates to process a good cause reinstatement. CMS estimates that Customer Service spends about 30 minutes handling each
GCR-related call, which is acceptable. However, the estimate of only 10 minutes to process a reinstatement appears to significantly understate the actual time required. While it might
take approximately 10 minutes for GCR team to review and approve the request, this does not reflect the additional work involved in submitting the reinstatement via RPC, as required
for requests received after the disenrollment effective date.
According to CMS Guidance (Good Cause FAQ), since a good cause reinstatement request is received after the effective date of the disenrollment these cases must be processed through
the RPC. The ten-minute timeframe suggested by CMS does not account for the extra steps necessary to create and submit the RPC request. Here’s how the process typically unfolds:

Supporting Statement Part-A
Good Cause Processes

Debra F.Lee
Operations Analyst II

Enrollment

When a GCR request is received from a member, the GCR team reviews and either approves or denies it. If approved, the appropriate model notice (Exhibit 21c or 21f) is sent to the
member. Once all past due premiums are collected, the request is sent to Enrollment via the complaint tracking module. The Enrollment Production representative then reviews the
request, updates the member’s account, sends out a reinstatement letter, enters the request in the RPC submission module, and updates the CTM tracking module, which generally takes
about 10–15 minutes.
Next, another Enrollment representative creates the RPC submission package, including a cover page and all required documentation (3 minutes), after which the Quality team reviews it
for accuracy (3 minutes). The Retro team then downloads the request, adds a cover letter and the submission spreadsheet (5 minutes). Subsequently, the representative logs into eRPT,
uploads the package, and submits it to RPC (3 minutes). The submission is then tracked while pending the FDR from RPC. Once the FDR is received, the representative logs into eRPT,
downloads and processes the FDR, and updates the member’s account to show that reinstatement is complete (5 minutes). Altogether, these steps add approximately 30 minutes to the
process.
Based on CMS’s figure of 54,789 beneficiaries per year, this would result in an additional 27,395 hours of work (54,789 x 0.5 hours), with an associated cost of $2,140,645.30 (27,395
hours x $78.14 per hour). Much of this extra workload and cost could be avoided if plans were allowed to submit Good Cause Reinstatements directly to CMS on the daily file for current
month (+1) requests (category 1). Only category 2 requests would continue to require RPC submission.

"Within these regulatory provisions, individuals disenrolled for nonpayment of premiums are afforded a grace period in which to request reinstatement. As part of the reinstatement
request process, they must demonstrate good cause for failure to pay within the initial grace period that led to their involuntary disenrollment and pay all overdue premiums within
three calendar months after the disenrollment date."
Need and Legal Basis

Caleif L. Brooks

PCP Assignment & Attribution

Members who are reinstated under CMS-approved Good Cause, where the member has requested reinstatement within the required timeframe and has paid all overdue premiums
within three (3) months of disenrollment, must be treated as continuously enrolled (no break in coverage) and must not be processed as new enrollments.
The risk is if Good Cause reinstated members are treated as new enrollments, PCP assignment logic may inappropriately reassign PCPs, resulting in member disruption and misalignment
with CMS-defined continuous coverage.