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

Additional Guidance for Chart Review Record (CRR) Submissions – Dated 8/28/2018

Summary: CMS released additional guidance to clarify the role of chart review records as part of the Encounter Data System.  

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

 

Updates to the Coverage Gap Discount Program (CGDP) – Dated 8/28/2018

Summary: CMS is informing plans of two upcoming changes to the Medicare Part D Coverage Gap Discount Program.  The memo also addresses the operational changes that will be made because of the changes to the Bipartisan Budget Act of 2018.

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

 

Indication-Based Formulary Design Beginning in Contract Year (CY) 2020 – Dated 8/29/2018

Summary: CMS provided additional guidance to plans on how they can expand the indication-based utilization management strategies to include indication-based formulary design beginning in CY 2020.  

Action: Informational to PACE plans that utilizes and submits a formulary to CMS.

 

2019 Step Therapy Qs & As – Dated 8/29/2018

Summary: CMS has issued a Questions & Answers document to accompany a previous HPMS memo regarding prior authorization and step therapy for Part B drugs.  The document can be found on the weblink provided.

Action: Informational to PACE plans that utilizes and submits a formulary to CMS.

 

2019 Step Therapy Qs & As – Dated 8/29/2018

Summary: CMS has issued a Questions & Answers document to accompany a previous HPMS memo regarding prior authorization and step therapy for Part B drugs.  The document can be found on the weblink provided.

Action: Informational to PACE plans that utilizes and submits a formulary to CMS.

 

Updates to MMP Medicare A/B Rate Methodology for CY 2019 – Dated 8/30/2018

Summary: CMS summarized the feedback and comments received on the proposed rate methodology for CY 2019 and provided information on CMS’ decision to implement the approach as proposed.

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

 

Medicare Advantage/Prescription Drug System (MARx) September 2018 Payment – INFORMATION – Dated 8/30/2018

Summary: CMS provided information about the September payment which is scheduled for September 1, 2018 and may require plan action:

  • National Medicare Education Campaign (NMEC)/ Coordination of Benefits (COB) User Fees
  • Third 2015 Final Risk Adjustment Reconciliation

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

 

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Advance Announcement of the Fall 2018 Software Releases – Dated 8/30/2018

Summary: CMS continues to implement software improvements to the enrollment and payment systems that support Medicare Advantage and Prescription Drug programs (MAPD).  The plan released of systems changes scheduled for fall 2018 include the following and may require plan action:

  • Changes to Default Enrollment Process for Newly Eligible Medicare Beneficiaries
  • Discontinuation of the MADP and MA-OEP
  • Limitations in Use of the SEP for Dually Eligible and LIS Beneficiaries
  • Inclusion of the NDCs on Certain OHI Records
  • Enhanced Point of Sale Drug Claim Edit Functionality (CARA)

Action: Applicable to PACE plans.  Refer to the memo for complete details on the release system changes.

 

2017 Attestations of Prescription Drug Event (PDE) Data, Direct and Indirect Remuneration (DIR) Data, Monthly Plan-to-Plan (P2P) Reconciliation Payments, and the Detailed DIR Report – Dated 8/30/2018

Summary: CMS requires all plans that were active in 2017 to electronically sign and attest to the below Part D data in HPMS:

-2017 Data Relating to CMS Payment to Medicare Part D Sponsor

-2017 Data Relating to Detailed DIR Report (except for PACE plans that submitted zero total dollars on their 2017 DIR Summary Report)

-2017 Record and Attestation of P2P Reconciliation Payments

Completion of the Record of P2P reconciliation Payments must be uploaded to HPMS at the same time the Plan to Plan Reconciliation Payment Data is signed.  The attestations will be available through HPMS on September 4, 2018 to September 14, 2018 NOON EST and is to be signed by the CEO, CFO, or COO.

Action: Applicable to PACE. Refer to the memo for complete details on how to complete the attestations.  Your Pharmastar Client Support Specialist can assist and is available to answer any questions you may have on the Record of P2P Reconciliation Payments.

 

Default Enrollment Option for newly Medicare Advantage Eligible Medicaid Managed Care Plan Enrollees (Formerly known as “Seamless Conversion Enrollment”) – Dated 8/31/2018

Summary: CMS released guidance to MAOs on the new default enrollment process established in the CMS-4182-F.  CMS will allow automatic enrollment of Medicaid managed care plan enrollees into an integrated dual eligible MA special needs plan offered by the same organization.  MAOs wanting CMS to conduct default enrollment will submit their proposal to CMS via HPMS starting on October 1, 2018.

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

 

Coverage Gap Discount Programs: September Participating Labeler Code – Dated 9/4/2018

Summary: CMS will update the below participating manufacturer labeler codes for the Coverage Gap Discount Program to include 71779 Verastem, Inc. and 25021 Sagent 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 these codes are accepted for Part D payment.  Pharmastar will make the necessary software adjustments to accommodate for the change.

 

Long-Term Institutionalized Resident Report – Dated 9/4/2018

Summary: The third 2018 LTI Resident Report will be distributed to plans on September 4, 2018.  Organizations will only receive a LTI report if they have LTI enrollees.  The layout of the file and a description of best practices related to plan’s use of the report is provided.  

Action: Informational to PACE plans who receives the LTI Resident Reports.

 

Release of the Revised CY2019 Medicare Communications and Marketing Guidelines – Dated 9/6/2018

Summary: CMS announced the release of an updated version of the CY 2019 Medicare Communications and Marketing Guidelines on the Managed Care Marketing website.  Changes to the guidelines were made based on questions and comments received by CMS.  A summary of the changes is provided.

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

 

Important Date Reminders

Date

      Item

September 4, 2018 – September 14, 2018 Noon EDT

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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