Learn more about CMS Updates that may impact your PACE Plan. FEATURED UPDATE: Performance Measure Validation Requirements for Medicare-Medicaid Plans
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Learn more about CMS Updates that may impact your PACE Plan.

Payment Reconciliation System (PRS) Part D Payment Reconciliation Reports Updates – Dated 6/20/2017

Summary: CMS provided updates to the PRS reports below:

  • PRS Inputs Report
  • PRS Reconciliation Results
  • Part D Exclusion from Reconciliation Report

Action: Applicable to PACE. Refer to the memo for complete details on the updates made to the reports.

 

Updates to the HPMS Marketing Module and Marketing Codes for Medicare-Medicaid Plans – Dated 6/20/2017

Summary: CMS released updates to the HPMS Marketing Module on the Medicare-Medicaid Plan specific updates, including edits to existing marketing codes.  

Action: Informational to PACE.

 

RAPS Submission of Data Collection Year Diagnosis Codes – Dated 6/20/2017

Summary: CMS specified that organizations are able to submit diagnosis codes to RAPS for years when a beneficiary was enrolled in a plan of a different parent organization.  

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

 

CMS Program Audit Validation/Close-Out Process and Listening Session – Dated 6/21/2017

Summary: CMS released information to clarify CMS’ expectations during the Validation Audit and Close-Out phase of program audits to address commonly asked questions and provide clarity on critical deliverables during this phase of the audit.  Additionally, CMS has a listening session focused on the Validation Audit and Close-Out phase of the audit on July 18, 2017 for those who are interested.

Action: Informational to PACE as the regulations mentioned in the memo 42 CFR 423.504 (d) (2) and 42 CFR 422.503 (d) (2) does apply to PACE.  To participant in the listening session, refer to the memo for complete details.

 

Qualified Medicare Beneficiary Program Enrollee Status Resources – Dated 6/21/2017

Summary: The QMB Program is a Medicaid benefit that pays Medicare premiums and cost sharing for certain low-income Medicare beneficiaries. CMS addressed questions and offered resources and potential strategies for plans to help identify enrollee status in the Qualified Medicare Beneficiary (QMB) Program and promote compliance by educating network providers about QMB billing rules and maintaining procedures that ensure network providers do not discriminate against enrollees based on their payment status.  

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

 

Performance Measure Validation Requirements for Medicare-Medicaid Plans – Dated 6/22/2017

Summary: CMS will be sponsoring ongoing performance measure validation of select core and state-specific measures to ensure the reported data are reliable, valid, complete, and comparable among Medicare-Medicaid Plans.

Action: Informational to PACE.  

 

Best Practices for Encounter Data Submission – Dated 6/22/2017

Summary: CMS compiled an initial list of Best Practices that organizations can implement to improve encounter data submissions.  Plans that are required to submit encounter data to CMS are encouraged to implement these best practices.

Action: Applicable to PACE. Refer to the memo for complete details on the best practices.

 

Reopening of the 2014 Final Part D Payment Reconciliation for Calendar Year Employer Group Waiver Plans (EGWPs) – Dated 6/22/2017

Summary: CMS completed the calculations for the reopening of the 2014 Final Part D Payment Reconciliation for Calendar Year EGWPs.  The payment reconciliation reports for reopening will be available in the plan’s reconciliation mailboxes at CSSC on June 27, 2017.

Action: Informational to PACE as PACE plans are not EGWPs.

 

CORRECTION – Payment Reconciliation System (PRS) Part D Payment Reconciliation Reports Updates – Dated 6/23/2017

Summary: CMS provided updates to the PRS reports below and has made corrections to the table numbering:

  • PRS Inputs Report
  • PRS Reconciliation Results
  • Part D Exclusion from Reconciliation Report

Action: Applicable to PACE. Refer to the memo for complete details on the updates made to the reports.

 

Final Medicare Part D DIR Reporting Requirements for 2016 – Dated 6/23/2017

Summary: On May 17, 2017, CMS released a proposed guidance regarding Medicare Part D direct and indirect remuneration (DIR) reporting requirements for Summary and Detailed DIR Reports for Contract Year 2016.  Comments on the proposed guidance were accepted through June 2, 2017.  This memo provides an overview of the comments and responses as well as the Final Medicare Part D DIR Reporting Requirements for 2016.  Plans can begin to submit the 2016 DIR on June 30, 2017 through 11:59 PM PT on July 31, 2017.  Resubmission for summary DIR reports for prior years will begin on July 1, 2017 through 11:59 PM PT on July 31, 2017.

Action: Applicable to PACE plans.  Refer to the memo for complete details on the DIR submission requirements.  Pharmastar will provide the DIR reports and notify your plan once they are available.  Please contact your Client Support Specialist if you have any questions.

 

Follow Up to the MMP Provider and Pharmacy Directory Webinar – Dated 6/27/2017

Summary: The presentation for the MMP Provider and Pharmacy Directory Webinar that was held on June 21 has been posted to the CMS website.  

Action: Informational to PACE.  Refer to the email for the CMS website link to review the presentation.

Read the Pharmastar Blog

Release of the Medical Loss Ratio (MLR) Reporting Tool for Contract Year 2016 – Dated 6/27/2017

Summary: CMS reminds plans of the requirement to submit an MLR report to CMS for each contract year pursuant to the regulations noted in the memo.  The memo announces the release of the MLR reporting tool and instructions for Contract Year 2016.

Action: Informational to PACE as PACE plans are not required to complete or submit a MLR report. 

 

2017 One-Third Financial Audit Civil Money Penalties – Dated 6/28/2017

Summary: For one-third financial audits conducted in 2017, CMS listed six types of audit deficiencies that will be considered for civil money penalties (CMP).  The list of deficiencies is not all inclusive as CMS is permitted to take enforcement actions for any substantial failures that may have adverse beneficiary impact.

Action: Applicable to PACE as PACE plans are not excluded from the one-third financial audits.  Refer to the memo for complete details on the six types of audit deficiencies considered for a CMP.

 

Coverage Gap Discount Program: July Participating Labeler Code Update – Dated 6/29/2017

Summary: CMS will update the below participating manufacturer labeler codes for the Coverage Gap Discount Program by July 1, 2017 to include:

Added: 29273 TG United Pharmaceutical

Deleted: 39506 Somerset Pharmaceuticals, Inc.

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 this codes are accepted for Part D payment,  Pharmastar will make the necessary software adjustments to accommodate for the change.

 

CORRECTION: Reopening of the 2014 Final Part D Payment Reconciliation for Calendar Year Employer Group Waiver Plans (EGWPs) – Dated 6/29/2017

Summary: CMS corrected the appeals due date from a previous memo from Friday, July 12, 2017 to Wednesday, July 12, 2017.  

Action: Informational to PACE as PACE plans are not EGWPs.

 

Medicare Advantage/Prescription Drug System (MARx) July 2017 Payment – INFORMATION – Dated 6/29/2017

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

  • 2014 Part D Reopening for Calendar Year EGWPs
  • Incorrect Adjustments for Medicaid Status
  • Incorrect Risk Factor Used in Some 2017 Payments
  • Missing Records on the Late Enrollment Penalty Data File
  • Second 2015 Final Model Output Reports (MORs)

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

 

Important Date Reminders

Date

      Item

June 29, 2017

CY 2016 Final PDE Submission Deadline

June 30 – July 31, 2017

11:59 PM PT

CY 2016 Direct and Indirect Remuneration (DIR) Submission Deadline

July 1 – July 31, 2017 11:59 PM PT

CY 2012-2015 Direct and Indirect Remuneration (DIR)

Re-submission Period (If any changes or errors)

Mid August-

Mid September 2017*

2016 Attestations of PDE, DIR Data, P2P Reconciliation Payments and Detailed DIR Report Submission Period

August 21 –

September 1, 2017

CY 2018 Formulary-Level Cumulative Opioid MED POS Edit Template Submission Period

April 2018

Social Security Number Removal Initiative (SSNRI) to Begin

January 2019

Enforcement Date for the Prescriber Enrollment Requirement

*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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