Learn more about CMS Updates that may impact your PACE Plan. FEATURED MEMO: Optional Combined Explanation of Benefits
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Learn more about CMS Updates that may impact your PACE Plan.

Availability of Medicare Health Outcomes Survey (HOS) 2014-2016 Cohort 17 Performance Measurement Data – Dated 10/20/2017

Summary: CMS announced the release of the Medicare HOS 2014-2016 Cohort 17 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 Survey (HOS) program.  

 

Announcement of Deadline for Second Final Reconciliation of Payment Year (PY) 2016 – Dated 10/23/2017

Summary: CMS announced the deadline for encounter data submissions for the second final reconciliation of Payment Year (PY) 2016 to be April 2, 2018.

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

 

Contract Year 2018 Monitoring of Marketed Comprehensive Formularies – Dated 10/24/2017

Summary: CMS announced the CY 2018 Monitoring of Marketed Comprehensive Formularies Analysis that will be conducted to compare marketed formularies on plan websites for CY 2018 to CMS-approved HPMS formularies that would be effective January 1, 2018.  Plans selected to participant in this analysis will be notified and provided additional information.  

Action: Informational to PACE. For PACE plans who utilizes a formulary, refer to the memo for complete details.

 

CY 2018 Core Reporting Requirements for Medicare-Medicaid Plans – Dated 10/25/2017

Summary: CMS released the CY 2018 Medicare-Medicaid Capitated Financial Alignment Model Core Reporting Requirements. Refer to the memo for a summary of substantive changes that were made as compared to the CY 2018 reporting requirements released on July 26, 2017.  

Action: Informational to PACE as PACE is not a Medicare-Medicaid Capitated Financial Alignment Model and is waived of the Part D reporting requirements.

 

Medical Loss Ratio (MLR) Report and Attestation Submission Reminder for Contract Year (CY) 2016 – Dated 10/25/2017

Summary: CMS reminds plans that the upload functionality for CY 2016 MLR Reports will be available in HPMS from November 3, 2017 to December 1, 2017.  The electronic Attestation functionality for CY 2016 MLR will be available December 4, 2017 to December 13, 2017.

Action: Informational to PACE as the MLR provision does not apply to PACE.

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Retail Pharmacy Network Access and Preferred Cost-Sharing Pharmacy Access Analysis Results for Q3 of CY 2017 – Dated 10/25/2017

Summary: CMS released the retail pharmacy access analysis for Q3 for 2017.  Plans have the opportunity to review the data and submit questions and/or concerns to CMS prior to CMS publishing the data to the CMS webpage.

Action: Informational to PACE.

 

Contract Year 2018 Medicare Readiness Checklist for Medicare-Medicaid Plans – Dated 10/26/2017

Summary: The Contract Year (CY) 2018 Readiness Checklist from CMS summarizes key operational requirements for organizations to review and perform their own internal audits for 2018 preparedness and eventual reporting purposes.

Action: Informational to PACE as this memo is specific to Medicare-Medicaid Plans.

 

2018 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, and Cost Plans – Dated 10/26/2017

Summary: The Contract Year (CY) 2018 Readiness Checklist from CMS summarizes key operational requirements for organizations to review and perform their own internal audits for 2018 preparedness and eventual reporting purposes.

Action: Applicable to PACE.  Refer to the memo for additional details and items applicable to your plan.  Any questions should be addressed to the appropriate individual(s) listed on attachment Appendix A.  Pharmastar will review and provide a list of the sections applicable to Pharmastar and supporting policy and procedures to how they will be handled.

 

Retail Pharmacy Network Access and Preferred Cost-Sharing Pharmacy Access Analysis Results for Q3 of CY 2017 – Dated 10/27/2017

Summary: CMS released the retail pharmacy access analysis for Q3 for 2017.  Plans have the opportunity to review the data and submit questions and/or concerns to CMS prior to CMS publishing the data to the CMS webpage.  The correct link is provided.

Action: Informational to PACE.  

 

Coverage Gap Discount Program: November Participating Labeler Code – Dated 10/27/2017

Summary: CMS will update the manufacturer labeler codes for the Coverage Gap Discount Program by November 1, 2017.  The updates include the following:

Added

70785 Ironwood Pharmaceuticals Inc.

10148 CoTherix, Inc.

70801 Flexion Therapeutics, Inc.

69344 Egalet US 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 has made the necessary software adjustments to accommodate for the updated codes.

 

Guidance for Encounter Data Submission – Dated 10/30/2017

Summary: CMS provided guidance and responses to questions from Medicare Advantage Organizations (MAOs) about encounter data records (EDRs).  The FAQs about EDRs is provided.

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

 

Medicare Advantage/Prescription Drug System (MARx) November 2017 Payment – INFORMATION – Dated 10/30/2017

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

  • CY 2016 Part D Payment Reconciliation
  • 2010 Overpayment Risk Adjustment Reconciliation

Correction to the 10/04/2017 HPMS Memorandum titled Announcement of the November 2017 Software Release.

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

 

Updated Eligibility Inquiry Responses to Accommodate New Medicare Beneficiary Identifier – Dated 10/30/2017

Summary: CMS released information of upcoming changes to the E1 responses received by pharmacies.  The changes are being implemented in support of the New Medicare Card Project.  Beginning in April 1, 2018, the E1 response will include the effective date of the MBI and the MBI if it’s been assigned to the beneficiary. Pharmacies can begin testing its capability to accept the new E1 response beginning March 1, 2018.

Action: Informational to PACE.  Refer to the memo for complete details on the E1 Responses.

 

New Quarterly Submission Process of Waivers for PACE Organizations – Dated 10/30/2017

Summary: CMS announced changes to the PACE waiver submission process.  Beginning the first quarter of 2018 calendar year, all PACE waiver requests should be submitted on the same day of each calendar quarter now applicable to the application process. To allow time for CMS and the plan to transition to the new waiver process, CMS will accept waivers on a rolling basis until December 29, 2017.

Action: Applicable to PACE. Refer to the memo for complete details on the new waiver process.

 

Updated CY2017 Part D Reporting Requirements Technical Specifications – Dated 10/31/2017

Summary: CMS revised the following sections in the 2017 Part D Reporting Requirements Technical Specifications to clarify the reporting:

  • Enrollment and Disenrollment
  • Grievances
  • Improving Drug Utilization Review Controls
  • Coverage Determinations and Redeterminations

Action: Informational to PACE as PACE plans are waived of the Part D Reporting Requirements.

 

Contract Year 2017-2018 Quality Improvement Project and Chronic Care Improvement Program Training Information – Dated 10/31/2017

Summary: CMS provided information on the upcoming contract year (CY) 2017-2018 training regarding the Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) requirements.  The training will be on November 8, 2017.  

Action: Informational to PACE as PACE is waived and exempted from the QIP and CCIP.  If interested in participating, refer to the email for complete details on the training.

 

QIP and CCIP Resource Document – Dated 10/31/2017

Summary: CMS announced the release of the Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) Resource Document.  The document can be found on the Medicare Advantage Quality website.

Action: Informational to PACE as PACE is waived and exempted from the QIP and CCIP program.

 

REVISION: Coverage Gap Discount Program: November Participating Labeler Code – Dated 10/31/2017

Summary: CMS reinsert labeler code 00186 which was inadvertently deleted.  

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 has made the necessary software adjustments to accommodate for the updated codes.

 

Optional Combined Explanation of Benefits – Dated 11/1/2017

Summary: CMS announced the option to have Medicare Advantage Organizations combine their Part C and Part D Explanation of Benefits (EOBs) beginning January 1, 2018 to reduce confusion caused by participant’s receiving similar but separate mailings during the same claims activity period. The use of the combined EOBs is not required. 

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

 

2019 Quality Bonus Payment Determinations and Administrative Review Process for Quality Bonus Payments and Rebate Retention Allowances – Dated 11/2/2017

Summary: CMS made available to Medicare Advantage (MA) Organizations a process to review payment determinations based on quality bonuses.  MA plans can request an administrative review of their Star Ratings for quality bonus payment determinations and rebate retention allowances by November 20, 2017.

Action: Informational to PACE.

 

Important Date Reminders

Date

      Item

January 2018

Sensipar- ESRD Treatment must be included in the ESRD PPS & no longer payable under Part D benefit.

April 2018

Medicare Diabetes Prevention Program services to be covered for eligible Medicare beneficiaries.

April 2018

New Medicare Card (Formerly known as 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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