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Learn more about CMS Updates that may impact your PACE Plan.

Annual Release of Part D National Average Bid Amount and other Part C & D Bid Information –Dated 7/29/2016

Summary:  CMS provided the determination of the amounts for the following:

  • Part D Beneficiary Premium
  • Part D National Average Monthly Bid Amount
  • Part D Regional Low-Income Premium Subsidy Amounts
  • Part D Income Monthly Adjustment Amounts
  • De Minimis Amount
  • Medicare Advantage EGWP regional payment rates
  • Medicare Advantage Regional Benchmarks

Action: Informational to PACE as this memo does not apply to PACE plans.


Coverage Gap Discount Program: August Participating Labeler Code Update –Dated 7/29/2016

Summary: CMS will update the manufacturer labeler codes for the Coverage Gap Discount Program by August 1, 2016.  The updates include:


  • 53097 The Pharma Network, LLC
  • 69315 Leading Pharma, LLC
  • 70181 Mitsubishi Tanabe Pharma Holdings America
  • 70301 OPKO Pharmaceuticals
  • 70510 MT Pharma America
  • 70564 Napo Pharmaceuticals

Action: Although the Coverage Gap Discount Program does not apply to PACE, the participating labeler codes are applicable because only brand name prescriptions with NDCs from these codes are accepted for Part D payment.  Pharmastar has made the necessary software adjustments to accommodate for the updated codes.


Invitation to Provide Feedback on the Contract Year 2017 Formulary Submission –Dated 8/1/2016

Summary: CMS invites plans to provide feedback on the CY 2017 formulary submission process in HPMS. Feedback should be limited to the specific topics noted and will take place from August 1, 2016 through August 5, 2016.

Action: Informational to PACE plans that submits formularies.


Updated 2015 Part D Appeals Upheld Data –Dated 8/1/2016

Summary: CMS updated the CY 2015 Part D Appeals Upheld data table in HPMS to include re-openings that occurred and were decided prior to May 1, 2016

Action: Informational to PACE.


CY2017 Final Actuarial Certification Deadline–Dated 8/1/2016

Summary: As part of the CY 2017 bid submission requirements, an actuarial certification must be submitted via the HPMS actuarial certification module for every Bid Pricing Tool uploaded to HPMS. Certifying actuaries were required to complete the initial certification process in June and now all final certifications are to be completed by August 10, 2016. If a certification is not submitted via HPMS, the bid(s) will not be considered for CMS review or approval.

Action: Informational to PACE. Refer to memo for further details.


2015 Medicare Health Outcomes Survey (HOS) HPMS Update –Dated 8/1/2016

Summary: CMS announced the release of the updated HPMS HOS module and availability of the reports and data to participant Medicare managed plans on the following:

  • 2013-2015 Medicare HOS Cohort 16 Performance Measurement Report
  • 2013-2015 Medicare HOS Cohort 16 Aggregate Score Analysis
  • 2013-2015 Medicare HOS Cohort 16 Star Ratings Validation
  • 2017 Medicare HOS Star Ratings Measures

Action: Informational to PACE.


2015 Medicare Health Outcomes Survey-Modified (HOS-M) Electronic Data –Dated 8/1/2016

Summary: CMS announced the availability of HOS-M 2015 beneficiary level data to PACE organizations and provides instructions on how to request the data.

Action: Applicable to PACE plans, who participated in the program.  Refer to memo for further details.


Registration Open: CMS’ 2016 Medicare Advantage & Prescription Drug Plan Fall Conference & Webcast Announcement (September 8, 2016) –Dated 8/1/2016

Summary: The fall MAPD plan conference and webcast registration window is open for all who is interested in participating.  The in-person registration will close on August 26th; however the webcast registration will remain open. 

Action: Informational to PACE. Refer to the attachment for a list of the session topics and information on how to register.


Coordinating State Passive Enrollment with Medicare Prescription Drug Plan Reassignment for January 2017 –Dated 8/1/2016

Summary: As provided in Medicare-Medicaid Enrollment Guidance, beneficiaries may only be passively enrolled or reassigned once per calendar year.  Information is provided on coordinating passive enrollment activities with Medicare’s annual reassignment process for States implementing demonstrations under Medicare-Medicaid capitated financial alignment model.

Action: Informational to PACE plans.  States scheduling passive enrollments for January 1, 2017 effective date should follow the steps in the memo to ensure passive enrollments “Trump” Medicare reassignments for the same person.


CY 2017 Medicare Advantage Out-of-Pocket Costs & Premium Information for Rebate Allocation –Dated 8/2/2016

Summary: The CY 2017 Medicare Advantage (MA) Out-of-Pocket (OOPC) values by service category and premium amounts based on the national average to assist in preparing bid submission during rebate reallocation is available on HPMS.

Action: Informational to PACE.


August 2016 release for the Drug Data Processing System (DDPS) –Dated 8/3/2016

Summary: CMS modified the edit code 879.  The edit is generated when the reported coverage gap discount is zero and generic cost sharing is reported for a PDE that is actually eligible for a gap discount.  Edit is updated to allow PDEs to be submitted with $0 cost in the gap. Affected PDEs can be resubmitted on or after August 14.

Action: Informational to PACE. Pharmastar will resubmit any affected PDEs.  


Model Notice Corrections/Policy Updates –Dated 8/8/2016

Summary: CMS released updates to clarify and correct the standardized language that Medicare Advantage Organizations and Part D Sponsors must use in the CY 2017 Annual Notice of Change/Evidence of Coverage and Part D EOB.

Action: Informational to PACE as PACE plans do not follow the MAPD marketing guidelines.   


Guidance regarding implementation of the procedural requirements under the regulation implementing Section 1557 of the Affordable Care Act of 2010 – Nondiscrimination Communication Requirements and Grievance Procedures –Dated 8/8/2016

Summary: CMS released guidance regarding the requirement to implement regulation Section 1557 of the Affordable Care Act into model materials and specific plan communications for Contract Year 2017.  The regulation prohibits discrimination on the basis or race, color, national origin, sex, age, or disability in certain health programs.

Action: Applicable to PACE.  Refer to memo for additional details.  Notify your Client Support Specialist if there is a specific format that your plan would like Pharmastar to use to include the taglines and/or specific language and contact information in the materials and communications Pharmastar creates for your members.  


Advance Announcement of the November 2016 Software Release –Dated 8/8/2016

Summary: The following areas of the enrollment and payment systems support Part D programs are scheduled for system changes in November 2016:

  • New Fields on Beneficiary Eligibility Query
  • Transaction Reply Codes for New Enrollment vs. Plan Benefit Package Change
  • Changes to Encounter Data Diagnosis Eligible for Risk Adjustment Report
  • New Part C Risk Adjustment Model beginning Payment Year 2017

Action: Informational to PACE plans.  Refer to memo for items applicable to your plan.


VBID: Changes for Model Year 2 –Dated 8/10/2016

Summary: CMS announced the changes to the Medicare Advantage Value-Based Insurance Design model test for CY2018.  

Action: Informational to PACE as PACE plans are not eligible to participate.


Update to CY 2016 Core Reporting Requirements for Medicare-Medicaid Plans –Dated 8/10/2016

Summary: CMS released the updated CY 2016 Medicare-Medicaid Capitated Financial Alignment Model Reporting Requirements and Value Sets Workbook.  Medicare-Medicaid Plans should follow the revised requirements for future submissions of all reporting periods that commence on or after January 1, 2016.  A summary of the changes is included in the memo.

Action:  Informational to PACE.


Results of the 2016 Part C and D Reporting Requirements Data Validation –Dated 8/10/2016

Summary: CMS released the results of the data validation reviews for CY 2015 Medicare Part C and D data which was conducted on April 1, 2016 and June 30, 2016.

Action: Informational to PACE as PACE is excluded from the Part C reporting requirements and waived of the Part D reporting requirements.


Contract Year 2016 Quality Improvement Project Plan Section and Annual Update Submission Windows –Dated 8/11/2016

Summary: CMS announced the submission window for the 2016 Quality Improvement Program for Medicare Advantage and Medicare-Medicaid Plans to be on October 2016.  The Annual Update is scheduled for January 2017.

Action: Informational to PACE.


2016 Call Center Monitoring Performance Metrics for Timeliness Study, Quarter 2 –Dated 8/11/2016

Summary: CMS released the elements and studies on the Part C and Part D call center monitoring for 2016 Quarter 2.

Action: Informational to PACE. Refer to memo for further details.


Specific Expectations Concerning the Timely Submission of Encounter Data by Medicare-Medicaid Plans (MMPs) to CMS –Dated 8/11/2016

Summary: CMS released clarification on the MMP encounter data submission requirements and expectations to ensure timely submissions.

Action: Informational to PACE.


Proposed Rule on Display – Programs of All-Inclusive Care for the Elderly –Dated 8/12/2016

Summary: CMS issued a proposed rule updating the requirements for PACE (CMS-4168-P).  The publish date is set for August 16, 2016.  Public comments are due October 17, 2016.

Action: Informational to PACE. PACE plans should review the proposed rule updates and provide any feedback/comments to CMS.


Stakeholder Call- Programs of All-Inclusive Care for the Elderly proposed rule –Dated 8/12/2016

Summary: CMS will hold a call on August 15, 2016 at 2pm ET to discuss the released proposed rule updating the requirements for PACE (CMS-4168-P).  To participate in the call:

Call 1-800-267-1577

Enter meeting number 999 551 883 then the # key

Action: Informational to PACE.  For individuals who are interested in participating, refer to email for the proposed rule link.


Updates on Previous HPMS Memos

CY 2017 Cumulative Opioid MED POS Edit Submission –Dated 7/21/2016

Summary: CMS expects Part D plans to implement either a soft and/or hard opioid edit based on morphine equivalent dose (MED) at the point of sale (POS).  Part D plans must complete the attached template and submit to HPMS between August 1, 2016 and September 1, 2016.  CMS also expects plans to have a written policy on the opioid edits at POS that CMS may request for review at any time.

Action: Informational to PACE.  Pharmastar will review and reach out to CMS for additional guidance.

8/12 Action Update: PACE plans are required to complete the template and submit to CMS.  Pharmastar has reached out to their software vendor on how this will be handled and will complete the template to provide to the plans. 

Reminder: Submission instructions are available via the HPMS “In The News” section on July 29, 2016.  The CY 2017 HPMS Formulary Submission Module & Reports Technical Manual will be updated to include detailed submission instructions.  


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Please note that this information is provided to you in summary form for general informational purposes only and does not constitute legal or regulatory compliance advice.  It is your responsibility to consult with your Compliance Officer and/or legal counsel to determine applicability of any regulation or standards referenced herein to your organization and/or processes.

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