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

2019 Medicare Parts C & D Reporting Requirements and Technical Specifications – Dated 12/14/2018

Summary: CMS posted the 2019 Parts C & D Reporting Requirements.  For Part D reporting, the Part D Retail, Home Infusion, and Long-Term Care Pharmacy Access section will be suspended in 2019.  The link to the reporting requirements is provided.

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

Medicare Parts C and D Preclusion List – Dated 12/14/2018

Summary: CMS provided additional FAQ information and a revised sample beneficiary notice for the Preclusion List Requirements.  

Action: Applicable to PACE.  Refer to the memo for complete details on the Preclusion List Requirements and how to access the list.

CY 2019 Formulary Information – Dated 12/17/2018

Summary: CMS provided key technical questions regarding the submitting of formulary for CY 2019.  

Action: Informational to PACE plans.  For PACE plans that utilizes and submits a formulary to CMS, refer to the memo for complete details.

Advanced Notice of Methodological Changes for Calendar Year (CY) 2020 for the Medicare Advantage (MA) CMS-HCC Risk Adjustment Model – Dated 12/20/2018

Summary: CMS proposed changes to the Part C risk adjustment model for 2020.  PACE plans will continue to use the same method of calculating risk scores that have been in place since 2015.  CMS does not propose to change the model used to calculate risk scores for PACE organizations for PY 2020.

Action: Informational to PACE as PACE plans risk adjustment model will not change for PY 2020.

Retail Pharmacy Network Access and Preferred Cost-Sharing Pharmacy Access Analysis Results for AEP CY 2019 – Dated 12/20/2018

Summary: CMS’s retail pharmacy access analysis for AEP CY 2019 is now available in HPMS for review.  Plans have the opportunity to review the data and submit questions/concerns prior to publishing the data to the CMS webpage.

Action: Informational to PACE plans.

Fall 2018 Past Performance Results Available in HPMS – Dated 12/20/2018

Summary: The results of CMS’ review of organizations’ performance for the period of August 2017 through September 2018 are now available on HPMS.  For organizations offering both Part C and D, there are separate C and D results.  Viewing instructions for results are included.

Action: Informational to PACE as PACE is excluded from the performance analysis.

2015 Benefit Year Closeout for the Coverage Gap Discount Program Invoicing Cycle – Dated 12/20/2018

Summary: CMS reminds plans of the upcoming closeout of the benefit year 2015 Coverage Gap Discount Program invoicing cycle.  Any PDE records reporting gap discount amounts for benefit year 2015 requiring submission, adjustments or deletions for any reason must be submitted by January 31, 2019 to be invoiced for manufacturer payment.

Action: Informational to PACE as PACE is not eligible to participate in the Coverage Gap Discount Program.

Medicare Plan Finder Plan Version of Out of Pocket Model for CY 2019 – Dated 12/21/2018

Summary: An updated version of the 2019 Out of Pocket Cost model is now available to use in calculating CY 2019 OOPC values, which are reflected in the Medicare Plan Finder.  The OOPC values displayed in the new version released are based on CY 2019 approved bids and may be used in forecasting CY 2020 bids.

Action: Informational to PACE plans as PACE provides only basic contact information on the Medicare Plan Finder website and waived of the Out of Pocket requirement and prevented from the application of cost-sharing.

2019 Timeliness Monitoring Project – Dated 12/21/2018

Summary: CMS will be conducting an industry wide monitoring project to collect data and evaluate for timeliness of processing of Medicare Advantage Part C organization determinations and reconsiderations and Medicare Prescription Drug Part D coverage determinations and redeterminations.  Plan active for both CY 2018 and CY 2019 will be subject to this monitoring effort.

Action: Informational to PACE as PACE is excluded from this monitoring project.

Medicare Prescription Drug Benefit Manual/Chapter 13- Premium and Cost-Sharing Subsidies for Low-Income Individuals/Section 60.4.2 Application to Months’/Days’ Supplies – Dated 12/21/2018

Summary: CMS released a revised Medicare Prescription Drug Benefit Manual Chapter 13 via HPMS.  In Section 60.4.2 of the chapter, a third paragraph with examples about the daily cost-sharing rate requirements was added.  Due to confusion from plans and PBMs, CMS would like plans to disregard the third paragraph until a new version of Chapter 13 is released.

Action: Informational to PACE. 

Medicare Advantage/Prescription Drug System (MARx) January 2019 Payment INFORMATION – Dated 12/27/2018

Summary: CMS provided information about the January payment which is scheduled for January 2, 2019 and may require plan action:

  • MARx Operating Calendar for 2019
  • 2019 National Medicare Education Campaign/Coordination of Benefits User Fees
  • Transaction Reply Code 086

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

Coverage Gap Discount Program: January Participating Labeler Code – Dated 12/27/2018

Summary: CMS will update the participating manufacturer labeler codes for the Coverage Gap Discount Program by January 1, 2019 to include the codes listed. 

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.

Important Date Reminders



January 1, 2019

Initial Preclusion List Available

April 1, 2019

Payment Denials and Claims Rejections Begin for the January 1, 2019 Preclusion List

*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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