Understanding CMS Complaint Tracking Module (CTM) for Medicare Plans
The CMS Complaint Tracking Module (CTM) is a system that enables SHIPs to assist beneficiaries with issues related to Medicare Advantage Plans or Part D Plans. By utilizing CTM, complaints are routed to CMS for resolution, potentially impacting plan performance measures. This article discusses the purpose of CTM, reasons for using it, and outlines the process to submit complaints effectively, along with examples of common scenarios and issue resolution timelines.
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CTM COMPLAINTS: DEBBIE BISSWURM EBS TRAINING DECEMBER 2020 WHAT, WHY AND HOW?
WHAT IS THE CMS COMPLAINT TRACKING MODULE ? A complaint resolution process that CMS has made available to SHIPs so they can assist beneficiaries who have issues with Medicare Advantage Plans or Part D Plans. Complaints are routed directly to CMS and immediately initiates the process. It is expected that resolution is attempted directly with the plan first. Complaints entered in CTM can impact the performance measures (star ratings) for plans.
WHY USE THE CTM SYSTEM ? When other options have been exhausted, this process can bring about a resolution for the client, such as enabling them to have coverage they may have lost to ensure they can access care and medications they need.
HOW TO GET A COMPLAINT SUBMITTED Always attempt to resolve the issue with the plan first. Work with your program attorney. If the issue cannot be resolved through the plan, contact: Debbie.bisswurm@gwaar.org. Gather information about the beneficiary and provide a summary of the situation. List of information needed on next slide.
Beneficiary Name: Beneficiary Medicare Number: Beneficiary date of birth Zip Code: LIS Status? Contact: (usually EBS) Contact phone number: (Best number to reach you) Plan Names and Plan s Id #s for both plans: Description of the problem: (Include what you are requesting - how you would like the complaint resolved.) INFORMATION NEEDED FOR THE COMPLAINT
ISSUE LEVELS CTM complaints usually take up to 30 days to resolve. Urgent Need Beneficiary needs medication and has less than 14 days of medication left. Usually resolved within 7 days. Immediate Need Beneficiary has no access to care and/or needs medication and has 2 or less days of medication left. Usually resolved within 2 days.
EXAMPLE 1 Problem with enrollment date. Client worked with an EBS and enrolled in a plan on the last day of open enrollment. Plan sent notice that the enrollment start date was February 1stinstead of January 1. Due to a need for medication, this ended up being an immediate need situation and CMS resolved the situation by correcting the enrollment date.
EXAMPLE 2 Client was basically tricked by an insurance agent into switching Advantage plans mid-year by making her feel that she didn t have any other option than to agree. It is unclear how the insurance agent made this change since client did not qualify for any SEP. This caused great stress for this beneficiary who wanted to be in her former plan. We requested that client be retroactively reinstated in her plan. RESOLUTION: CMS took action to enroll client based on Marketing Misrepresentation into her former plan and disenroll her from plan that agent enrolled her in. Plan was following up on the alleged mis-representation.
EXAMPLE 3 90 year old client worked with EBS who assisted in enrolling him, as well as his wife and his son, into a plan during open enrollment through the Medicare Plan Finder. Enrollment Confirmation for was received. The enrollment went through for client s wife and son and took effect 1/1/2019. However, client discovered that his enrollment did not go through so he worked with EBS who called plan multiple times without resolution. Plan then agreed to enroll the client into the plan with an effective date of April 1. That would have been an incorrect enrollment date and it appeared the plan was using the Medicare Advantage Open Enrollment Period for this change. RESOLUTION: We used this CTM process to get the client enrolled into the plan with the correct date 1/1.
EXAMPLE 4 Client was a dual eligible beneficiary who enrolled in a plan during Fall open enrollment period. She later wanted to find out which local dentist she could go to, so she called the plan. Because of this call, the Plan Rep upgraded the client to an enhanced plan with dental coverage at a cost of $39 month. Client did not request or need this coverage. Client tried to resolve through the plan and then contacted EBS for help. RESOLUTION: We were able to use the CTM process to cancel the enhanced plan and get the client back into her former plan.
