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

Coordinating State Passive Enrollment with Medicare Prescription Drug Plan Reassignment for January 2019 – Dated 7/27/2018

Summary: CMS provided information on coordinating states’ passive enrollment activities with Medicare’s annual reassignment process for states implementing demonstrations under the capitated model of the Financial Alignment Initiative.  Specific timeframes on the passive enrollment is listed.

Action: Informational to PACE.


Invitation to Provide Feedback to the Contract Year 2019 Formulary Submission – Dated 7/27/2018

Summary: CMS is looking for feedback on the CY 2019 formulary submission process in HPMS.  The feedback period will take place from July 30, 2018 through August 3, 2018.  HPMS access is not required to submit feedback via the online application.

Action: Informational to PACE.  For individuals interested in providing feedback, refer to the memo for complete details.


Annual Release of Part D National Average Bid Amount and Other Part C & D Bid Information – Dated 7/31/2018

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.  Refer to the memo for items that may be applicable to your plan.


Medicare Advantage/Prescription Drug System (MARx) August 2018 Payment – INFORMATION – Dated 7/31/2018

Summary: CMS released information about the August payment and other payment related items that may require plan action:

  • No Software Release for MARx
  • 2018 Mid-Year Risk Adjustment Reconciliation
  • Second 2016 Final Risk Adjustment Reconciliation
  • Number of Uncovered Months Resent Record Data Cleanup
  • 2017 Interim Final Model Run ESRD Model Output Reports

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


Enrollment Guidance Policy Changes and Updates for Contract Year 2019 – Dated 7/31/2018

Summary: CMS provided guidance and enrollment form/model notice updates for contract year 2019 to the Medicare Managed Care Manual and Medicare Prescription Drug Benefit Manual.  

Action: Informational to PACE.  Refer to the memo for items that may be applicable to your plan.


Coverage Gap Discount Program: August Participating Labeler Code – Dated 8/1/2018

Summary: CMS will update the below participating manufacturer labeler codes for the Coverage Gap Discount Program by August 1, 2018 to include 00254 Par Pharmaceutical.

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 will make the necessary software adjustments to accommodate for the change.


Guidance on the Process for Implementing Passive Enrollment Flexibilities to Protect Continuity of Integrated Care for Dual Eligible Beneficiaries – Dated 8/1/2018

Summary: CMS provided guidance to the specified integrated Dual Eligible Special Needs Plans on the new passive enrollment authority established in CMS-4182-F.  

Action: Informational to PACE as the memo is specific to Special Needs Plans and does not apply to PACE.


2019 National MMP Enrollment Guidance & Exhibits – Dated 8/2/2018

Summary: The Medicare-Medicaid Coordination Office completed and finalized the MMP National Enrollment Guidance & Exhibits.  The guidance will be effective January 1, 2019.  A list of the key policy/operational flexibilities that have been updated since 2017 is provided.

Action: Informational to PACE.


CY2019 Final Actuarial Certification Deadline – Dated 8/2/2018

Summary: As part of the CY 2019 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 all final certifications are to be completed by August 13, 2018.  If a certification is not submitted via HPMS, the bid(s) will not be considered for CMS review or approval.

Action: PACE plans should review the status of this requirement with their actuaries.  Refer to the memo for complete details.


Contract Year 2019 Marketing and Beneficiary Communications Guidance for Medicare-Medicaid Plans – Dated 8/3/2018

Summary: CMS issued the Medicare Communications and Marketing Guidelines for CY 2019.  A link to the webpage is provided.  The sections modified in the CY 2019 guidelines is listed.

Action: Informational to PACE.


2018 Medicare Health Outcomes Survey HPMS Update – Dated 8/3/2018

Summary: The following reports and data for Medicare managed care plans participating in the Medicare Health Outcomes Survey are now available through HPMS:

  • 2015-2017 Cohort 18 Medicare HOS Performance Measurement Report
  • 2015-2017 Cohort 18 Medicare HOS Star Ratings Validation
  • 2015-2017 Cohort 18 Medicare HOS Aggregate Score Analysis

Action: Informational to PACE.  PACE does not participate in the HOS survey.  The Health Outcomes Survey-Modified (HOS-M) reports for 2014-2017 are also available in HPMS for PACE plans who participated in the program.  


Retail Pharmacy Network Access and Preferred Cost-Sharing Pharmacy Access Analysis Results for Q2 CY 2018 – Dated 8/6/2018

Summary: CMS completed the retail pharmacy access analysis for Quarter 2 CY 2018 which is now available in HPMS for review.  CMS gives plans the opportunity to review the data and submit questions and/or concerns prior to the data being publish.  

Action: Informational to PACE.  The pathlink to the data is provided.


Prior Authorization and Step Therapy for Part B Drugs in Medicare Advantage – Dated 8/7/2018

Summary: CMS issued new guidance for Medicare Advantage (MA) plans on the use of step therapy for Part B drugs, beginning of January 1, 2019, as part of a patient-centered care coordination program.  CMS acknowledges the use of step therapy for Part B drugs as a recognized utilization management tool and to help lower drug prices.  MA plans may apply step therapy to control utilization of services that does not create an undue access barrier for beneficiaries.  CMS does encourage MAPD plans to use their pharmacies and P&T committees to determine when it is appropriate to use step therapy for selected drugs in Part B.

Action: Informational to PACE plans that utilizes a formulary.  Refer to the memo for complete details.


Re-Determination of Part D Low-income Subsidy Eligibility for 2019 – Dated 8/7/2018

Summary: CMS provided organizations with information and guidance on re-determination of LIS eligibility and the responsibility of plans to conduct outreach to members who no longer automatically qualify for LIS in 2019.

Action: Applicable to PACE.  Refer to the memo for guidance and plan responsibilities.


Submission Template – CY 2019 Opioid Safety Edit and Participation in Drug Management Programs – Dated 8/8/2019

Summary: CMS provided information regarding the template plans should utilize to submit information about CY 2019 opioid point-of-sale safety edits and implementation of a drug management program to CMS.  Plans are to complete the template and submit via HPMS to CMS between August 20, 2018 to August 27, 2018 at 5 PM EST.  

Action: Applicable to PACE plans if they adjudicate claims at the point-of-sale.  Refer to the memo for complete details.  Pharmastar will work with software claims processor on how the edits will be implemented.  An email to all active Pharmastar PACE plans on how to complete the template is forthcoming.


First Plan Preview of 2019 Star Ratings Data – Dated 8/8/2018

Summary: CMS inform plans the opportunity to preview their Star Ratings data in HPMS.  The first plan preview will be held from August 9-17, 2018.  The second plan preview will be conducted in September.  Plans should notify CMS of any data issues or errors to allow sufficient time for CMS to investigate and process the data corrections.

Action: Informational to PACE as PACE plans do not participant in the MA plan Star Ratings.


2018 Call Center Monitoring – Availability of Performance Metrics for Accuracy and Accessibility Study – Dated 8/9/2018

Summary: The following two data sets for the 2018 Performance Metrics for Accuracy and Accessibility Study will be available for Plans to review within the next few days in HPMS:

-Call center accuracy and accessibility performance metrics data

-Call level raw data

Action: Informational to PACE.  Refer to the email for complete details. Plans may access the performance metrics in HPMS by following the pathlink provided.


2019 Full Risk Contract Option Election – Dated 8/9/2018

Summary: CMS reminds plans that they have the choice of payment options for enrollees who have 12 months of entitlement to Part a and less than 12 months of Part B enrollment during the data collection year.  Plans can be paid for these enrollees as either “full risk” or “new enrollee” beneficiaries.  Plans can choose this option for their Part C and Part D risk scores.  Organizations that wish to confirm the status of their Full Risk Option election can access the Full Risk Contract Option Election Data in HPMS by September 21, 2018.

Action: Applicable to PACE.  Refer to the memo for complete details and additional information.   


Important Date Reminders



August 20, 2018 – August 27, 2018 5pm EDT


CY 2019 Opioid Point-of-Sale Safety Edits Template Submission

August 31, 2018

Deadline for plans to review and update current Opioid POS beneficiary-specific claim edit information in MARx.


Mid-September 2018*

2017 Attestations of PDE, DIR Data, P2P Reconciliation Payments and Detailed DIR Report Submission Period

January 1, 2019

Preclusion List Requirement Begins

*Subject to change, forthcoming information to be release by CMS.


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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