10.27.2016 Pharmastar CMS Summary Update FEATURED MEMO: Contractor Change for Medicare Prescription Drug Benefit Final Part D Payment Process
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Learn more about CMS Updates that may impact your PACE Plan.

CY 2015 Part D Payment Reconciliation Final –Dated 10/8/2016

Summary: CMS completed the 2015 Final Part D Payment Reconciliation. The payment reconciliation reports will be available in the reconciliation mailboxes at the Customer Service and Support Center (CSSC) on October 13, 2016. 

Action: Applicable to PACE.  Refer to the memo for complete details.  If your plan cannot access the reports, please contact CSSC at 877-534-2772.

 

Contractor Change for Medicare Prescription Drug Benefit Final Part D Payment Process –Dated 10/12/2016

Summary: CMS announced the new Reconciliation Support Contractor, Pacific Consulting Group, who will assist CMS beginning September 2016 with the Medicare Prescription Drug Benefit final Part D payment process. The Part D payment reconciliation process remains the same and will not change.  However, there will be a change to the mailing address for sending reconsideration requests.  Information on this change will be released in a future HPMS memo.

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

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Attestation of Prescription Drug Event Data (PDE) and Direct and Indirect Remuneration (DIR) Data related to the 2011 Reopening –Dated 10/14/2016

Summary: Due to the global reopening of the benefit year 2011 Part D payment reconciliation, CMS is requesting all plans, who offered an active Part D plan in 2011, to sign the Attestation of Data Relating to CMS Payment to a Medicare Part D Sponsor by noon ET, November 7, 2016.  An electronically signed copy of the attestation is required to receive risk sharing and reinsurance payment adjustments resulting from the reopening.

Action: Applicable to PACE. Refer to the memo for complete detail and instructions for completing the Part D Attestation. 

 

October 2016 Release Outlier Prescriber Risk Assessment of Schedule II Contracted Substances- Action Requested –Dated 10/14/2016

Summary: CMS evaluated PDE records with dates of service between July 1, 2015 to June 30, 2016 and identified outlier prescribers who exhibited patterns of prescribing extremely high amounts of Schedule II Controlled Substances that were higher than their geographic taxonomy peers.  Outlier prescribers does not itself indicate inappropriate activity; however, further scrutiny and investigation by the plan and CMS can determine if improper prescribing has occurred.  The methodology and data on all outlier prescribers are provided with the memo as separate attachments.

Action: Applicable to PACE plans. Refer to the memo and attachments for complete details.  Pharmastar will review the outlier prescribers list and if any prescribers have been identified for your plan, you Client Support Specialist will contact you and provide you with information to help assist you in investigating if the physician’s prescribing patterns were appropriate.  

 

Guidance on Outreach for Information to Support Coverage Decisions –Dated 10/18/2016

Summary: As a result of repeated audit findings, CMS released clarification on the guidance related to conducting sufficient outreach from providers and prescribers when adjudicating coverage decisions.  The guidance addresses the number of timing of the attempts made, potential method(s) of contact and the content of messaging when requesting for the information needed to make an informed coverage decision.   

Action: Informational to PACE. Refer to the memo for further details on the guidance.

 

Availability of Medicare Health Outcomes Survey (HOS) 2013-2015 Cohort 16 Performance Measurement Data –Dated 10/18/2016

Summary: CMS announced the release of the Medicare HOS 2013-2015 Cohort 16 Performance Measurement beneficiary level data.  The HOS data are intended to support quality improvement activities and initiatives.  Plans can obtain their data from HSAG by contacting the HOS information and technical support email provided.

Action: Informational to PACE as PACE does not participant in the Health Outcomes (HOS) survey program.

 

Phase II MAO-004 Distribution –Dated 10/20/2016

Summary: CMS announced that it will distribute revised MAO-004 reports in the fall of 2016. The MAO-004 reports provide organizations with the diagnoses from encounter data and chart review records accepted by the Encounter Data Processing System (EDPS) that are eligible for risk adjustment. After historical reports have been distributed, CMS will continue to distribute MAO-004 on a monthly basis.

Action: Applicable to PACE. Refer to the memo for complete details. Questions about the report can be directed to RiskAdjustment@cms.hhs.gov.

 

Release of Notice of Intent to Apply for Contract Year 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) and Related CY 2018 Application Deadlines –Dated 10/20/2016

Summary: CMS announced the release of the Contract Year (CY) 2018 Notice of Intent to Apply (NOIA) web tool and key dates for the CY 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) application cycle. The memo details the CY 2018 application cycle key dates.

Action: Informational to PACE as PACE plans have their own application process.

 

Issuance of Program of All-Inclusive Care for the Elderly Marketing Guidelines and PACE Marketing Mailbox –Dated 10/20/2016

Summary: CMS released a draft of the PACE Marketing Guidelines for comment.  There have been extensive updates to the guidelines; therefore, plans should review the document in its entirety.  Questions on the guidelines can be sent to the direct link provided in the memo no later than 5pm EST November 10, 2016.

Action: Applicable to PACE. Refer to the memo for additional information on the updated guidelines.

 

Release of Notice of Intent to Apply for Contract Year 2018 Medicare-Medicaid Plan (MMP) and Related CY 2018 Application Deadlines –Dated 10/20/2016

Summary: CMS announced the release of the Contract Year (CY) 2018 Notice of Intent to Apply (NOIA) web tool and key dates for the CY 2018 Medicare-Medicaid Plan (MMP) application cycle.  The memo details the CY 2018 application cycle key dates.

Action: Informational to PACE as PACE plans have their own application process.

 

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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